Camp Lookout Camper Application

Please read the following:
In keeping with the college's mission of providing eduction to young people demonstrating financial need, Camp Lookout is for Stone and Taney County children (ages 8-12) who otherwise would not be able to experience a summer camp program. Limited finanicial information will be obtained to determine eligibility. Immunization records are needed for first-time campers.


Camper Info

* - Indicates required field.

*First Name:


*Last Name:


Preferred Name:

  (Note: Please adhere to our rules regarding ages.
    We do not accept 7 year-olds or 13 year-olds.)


*Birthday:

*Gender:

*Last school attended:


*Last grade completed:


*Who does the camper live with:


*Parent's Marital Status:
*Parent(s) or Guardian's Name:


*Mailing Address:


*City:
*State: *Zip:
Email Address:

   (Note: A phone number where you can be reached must be provided. We cannot consider your child without one.)
*Primary Phone Number:
*Secondary Phone Number:

Church Affiliation:

Father's Occupation:
Mother's Occupation:


Emergency Contacts (other than parents)

(We cannot consider your child without this information)

Contact 1:
*Contact Name:

Contact 2:
*Contact Name:

*Phone:
Secondary Phone
(if applicable):
*Phone:
Secondary Phone
(if applicable):

We do not accept week requests; however, please list those dates that your child will be unavailable to attend camp and why. Please keep in mind children cannot leave camp and return (i.e. for baseball games, family reunions). We do not accept cabin mate requests; however, if your child must travel with another camper, please list their names.





Please explain:



Please provide the year(s):

*T-Shirt Size:

Financial and Insurance Information *Yearly Income:

Attention: Camp Lookout does not offer insurance coverage for campers while in residence at camp. Please fill out this information box regarding your family insurance policy.


Carrier or Plan Name Group #
Carrier Address
Name of insured Relationship to Camper

Release Statements

Release of Liability Agreement

My son/daughter has permission to participate in the activities at Camp Lookout. In consideration of my child's attence at Camp, I understand I am accepting full responsibility for my son/daughter. If an accident should occur injruing my son/daughter, including, but not limited to, death, or serious injury, I, on behalf of myself, my heirs or successors, hereby release Camp Lokout, College of the Ozarks, and their trustees, directors, officers, agents, employees, counselors, or students from liability. I have filled out the information box regarding my family insurance policy. I understand that any expenses incurred for medical treatment of my son/daughter will be my responsibility. I agree on behalf of myself and my heirs and successors to indemnify and hold harmless Camp Lookout and College of the Ozarks from any loss, cost, judgement or other harm, including attorney fees, which might come to them arising from my child's attendance at Camp Lookout.



Permission to Use Phtos/Videos

I grant permission for Camp Lookout or College of the Ozarks to photograph, record, or video my child during camp and to use those materials for promotional or other purposes.



Camper Health History

The following information must be completed by the parent/guardian. The intent of this information is to provide camp health care personnel the background of the camper, in order to provide appropriate care. Please leave both textboxes blank if the allergy or health issue does not apply to your child.

Medication Allergy: Reaction Treatment:
Insect Stings: Reaction Treatment:
Animal Dander: Reaction Treatment:
Seasonal Allergies: Reaction Treatment:
Food Allergy: Reaction Treatment:
Asthma: Reaction Treatment:
Poison Ivy: Reaction Treatment:

Please explain:


Is there any particular information about your child (medical, emotional, dietary treatment, ongoing medication, allergies, special cirumstances, etc.) that you want to be certain the Camp Director and/or counselor are aware of? If so, please give a detailed explanation:

Medications Being Taken

Please list ALL medication(s) (including over-the-counter or non prescription drugs) taken routinely. Bring enough mediation to last the entire time at camp. Keep it in the original packaging/bottle that identifies the prescription physician (if a prescription drug), the name of the medication, the dosage, and the frequency of administration.



Identify any medication taken during the school year that the camper WILL NOT take during the summer:



Restrictions

The following restrictions apply to this camper:

Dietary:

*Are there any restrictions that apply to your child(i.e. what cannot be done, what limitations are necessary)?


Parent/Guardian Authoization: This health history is correct and complete as far as I know, and the person herein described has permission to engage in all camp activities axcept as noted above.



Important:The Statement in the Box Below Must be Read and Signed for Camp Attendance

PERMISSION TO PROVIDE MEDICAL TREATMENT OR EMERGENCY CARE
I hereby give permission to Camp Lookout to make any and all arrangements deemed appropriate and in the best interests of my son/daughter for medical, surgical, and dental care. In the event I cannot be reached in an emergency, I hereby give permission to a healthcare provider to secure and administer treatment, including hospitalization, for my son/daughter. I understand that parental permission is required for operative procedures on minors. By checking the box, I am giving my permission that operative procedures may be promptly carried out. I understand that all costs related to such care are my responsibility. I understand that Camp Lookout is not responsible for my son's/daughter's pre-existing injuries or illnesses or any aggravation of these conditions. I understand that Camp Lookout will not assume responsibilities for illness or injury incurred while my son/daughter is participating in camp activities.