Junior Application

JUNIOR CAMP
APPLICATION

JUNIOR

JUNIOR CAMP
APPLICATION

JUNIOR

JUNIOR CAMP
APPLICATION

APPLICATION

Complete and submit your camp application here!

$265 per camper; $235 each additional sibling

$265 per camper

$235 each additional sibling

$265 per camper; $235 each additional sibling

$265 per camper

$235 each additional sibling

$265 per camper; $235 each additional sibling

PAY NOW

* indicates required field

Camper Information

First & Last Name *

Gender *

Age *

Birthdate *

T-shirt Size *

Home Address:

Line 1 *

Line 2

City *

State *

Zip *

Camper Phone Number (if applicable):

Roommate Request (optional):

I would like to room with… (one choice only, with both campers requesting each other)

First & Last Name *

I have read the general information section in this brochure, and I agree to comply with the dress and conduct regulations while at camp. *

Camper Signature:

Signature *

Date *

Parent/Guardian Signature:

Signature *

Date *

Other Notes:

How did you hear about Camp Kupono? *

Informed Consent *

I give consent for my child’s voice/likeness to be used non-exclusively, and royalty-free for advertisement and promotional purposes by Camp Kupono.

Medical Information *

My child may receive the following medications at the discretion of the camp nurse.

Allergies: Benadryl (Diphenhydramine)

Anti-itch: Ivarest, Caladryl, Hydrocortisone cream, Campho Phenique, Lavender Oil

Decongestant: Sudafed, Peppermint Oil (aromatic)

Indigestion: Mylanta

Pain/fever: Tylenol (Acetaminophen), Advil (Ibuprofen)

Sunblocks/sun burn relief: Lavender Oil, Aloe

Topical Antibiotics: Triple Antibiotic Ointment

List any exceptions here:

In case of medical emergency, I understand every effort will be made to contact parents or guardians of the camper. In the event they cannot be reached, I hearby give permission to the physician selected by the camp to hospitalize and secure proper treatment (i.e. injections, anesthesia, surgery, etc.) for my child named on the application. I agree to the release of any records necessary for treatment, referrals, billing, and insurance purposes. I also affirm that the medical information on this form is complete and correct. *

Parent/Guardian Contact:

First & Last Name *

Phone Number *

Email *

Emergency Contact Other Than Parent:

First & Last Name *

Contact Relationship *

Phone Number *

List the FULL NAME and CONTACT of all other people who are allowed to drop off/pick up your camper:

Parent/Guardian Signature:

Signature *

Date *

Other Notes:

How did you hear about Camp Kupono? *

Waiver Form *

Please read the attached PDF.

Read Waiver

I have read and consent to the attached waiver.

I, THE UNDERSIGNED PARTICIPANT, AFFIRM THAT I AM OF THE AGE OF 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. CERTIFY THAT I HAVE READ THIS AGREEMENT. THAT I FULLY UNDERSTAND ITS CONTENT AND THAT THIS RELEASE CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.

I, THE UNDERSIGNED PARTICIPANT, AFFIRM THAT I AM OF THE AGE OF 18 YEARS OR OLDER, AND THAT I AM FREELY SIGNING THIS AGREEMENT. CERTIFY THAT I HAVE READ THIS AGREEMENT. THAT I FULLY UNDERSTAND ITS CONTENT AND THAT THIS RELEASE CANNOT BE MODIFIED ORALLY. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND THAT I AM SIGNING IT OF MY OWN FREE WILL.

Participant's Signature (If under 18, enter "NA" in the blank and complete the next section.)

Date

In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:

In the event that the participant is under the age of consent (18 years of age), then this release must be signed by a parent or guardian, as follows:

I HEREBY CERTIFY that I am the parent or guardian of [participant's name], and do hereby give my consent without reservation to the foregoing on behalf of this individual.