Camper Registration & Health History
Full Name of Camper:*
Date of Birth*
Grade in 2022
Camper T-Shirt Size
Relationship to Camper*
Address City/State/Zip *
Relation to Camper*
Parents and guardians are responsible for medical expenses incurred for illness or injury at Choir Camp.
Name of Insurance Company:
Policyholder's Date of Birth:
Insurance ID Number:
Insurance Group Number:
Medicaid ID Number:
If no insurance, responsible party:
Please list any allergy:
Date of Last Reaction:
List over-the-counter medications the camper cannot receive for minor symptoms.
Operations/Serious Injuries & Dates:
Chronic or Recurring Illnesses:
Please list medications that will be given to camp nurse on check-in, including drug, dosage and condition requiring the medication. Prescribed medication and inhalers MUST be in original container with pharmacy label that includes camper’s name, valid date, instructions and Dr’s name. Sample medications MUST have signed physician’s letter. Over-the-counter medications MUST be in original packaging with valid expiration date.
Name of church:*
Camper’s musical ability will be assessed on arrival at camp. Please describe camper’s past musical experiences or lessons, choir or band:
No previous musical or choral experience is required for attendance.
Is the camper part of a choir, band or orchestra?
What are your camper’s interests, hobbies, and activities?
Describe your camper’s personality:
Please include limitations, characteristics, or behavioral issues which could help the staff in working (sunburn sensitivity, sleepwalking, bedwetting, etc.)
Camper lives with:
Please rate your camper in the following areas:
4 = Excellent
3 = Good
2 = Needs Improvement
1 = No experience
Ability to live cooperatively in a community setting for a period of six days:
Ability to independently take care of their own personal needs (i.e. showering, personal hygiene, dressing, etc.)
Ability to stay away from home for an extended period of time:
Roommate requests will be honored as much as possible, but no requests are guaranteed. Rooms are double-occupancy, two room suites with showers.
1 (First and Last Name)
2 (First and Last Name)
The Episcopal Diocese of Texas | 1225 Texas Street, Houston, TX US 77002 | 800.318.4452
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