Please complete and submit a separate form for each child
First Name
Last Name
Mother Email Address
Father Email Address
Camper Email Address
Birthday
Month
Day
Year
Age:
Current grade:
Gender:
Number of Summers Completed at Chipinaw
Name of current school:
Legal guardian of camper
Other legal guardian relationship:
Does child live with both parents?
If no, with whom?
Are parents divorced?
T-Shirt Size
Camp Experience
Prior camp experience and results
Is the camper enthusiastic about coming to camp?
Does the camper have any fears we should know about, such as darkness, swimming, etc.?
Would you like your child to lose, gain or maintain their weight?
What mealtime problems should we anticipate and how should we deal with them ? (eating peculiarities, special diet, food allergies)
What physical symptoms does your child display before the onset of illness?
Are there any precautions (allergies, physical disabilities, bed wetting, attention deficit problems, etc.) which the camp should be aware of?
Moms and Dads: In the space provided below please write a personal note to your child's counselors. The counselors will read this section several days before your child arrives at camp. This is your chance to give them information you feel they should know to make your child's camp experience successful. This section is optional and should be kept short and to the point; just the facts please.
Please include any additional confidential information.
Activity Information
List top 3 favorite activities:
List 3 activities you would like to improve your skills:
List 3 activities you would like to try for the first time:
"Mutual" Bunk Placement Request
Please Note: All special requests must be in writing.
What suggestions do you have to assist in proper bunk placement?
List maximum of 2 friends you would like to bunk with (We will do our best to honor mutual requests). Please do not request bed placement as these requests will not be honored.