Camper Information

First Name

Last Name

Birthdate

Biological Sex

Male

Female

Camp Attending

T-Shirt Size

Canteen Card

Full Canteen Card

Half Canteen Card

None

Medical Information

Is your TETANUS Booster up to date?

Yes

If YES on TETANUS Booster, please list the date below.

Known allergies and reactions

Any specific dietary restrictions?

Other health concerns

Recent surgery, injury, or conditions that might restrict your child from participation in camp activities

I allow Cyokamo to give my child over-the-counter medication (Ibuprofen/Benadryl) for minor medical treatment.

Yes

Physician Name

Physician Phone

Medical Insurance Company

Policy Number

Company Address

Company Phone

Agreements and Releases

I allow my child to leave the CYOKAMO campus for off-campus activities during the week of camp.

Agree

I allow CYOKAMO to use photographs or video footage shot at camp of my child for the use of promotional materials.

Agree

I allow CYOKAMO Camp Management to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery for my child as named on this form. I understand that every effort will be made to contact me in case of such an emergency and, if possible, before any such medical treatment is administered. I release the camp from any responsibility other than normal supervision and care. In case of accident, I will not hold CYOKAMO or any staff members, management, or officers liable unless guilty of negligence.

Agree

All of the above medical information on my child is correct.

Agree

In consideration of the privilege of participating in CYOKAMO recreational activities (including Archery Tag): Guest agrees to exercise caution and to obey all instructions of the CYOKAMO Staff. I give permission for any medical treatment that the CYOKAMO staff may deem necessary in case of emergency. Guest (and Guest’s parent or legal guardian, if Guest is under 18) UNCONDITIONALLY RELEASES AND ABSOLVES Camp CYOKAMO, its staff, cooperative churches and all other persons from any and all liability in connection with any injury or death of Guest, or damage to property, sustained while participating in CYOKAMO recreational activities (including Archery Tag), including specifically any negligence of Camp CYOKAMO and its staff: and agrees to INDEMNIFY AND HOLD HARMLESS Camp CYOKAMO and the cooperative churches, its staff, and all other persons from any and all damages, costs, and expenses that any of them may incur in connection with, therewith, including for their own negligence, or in connection with evacuation or medical treatment.

Agree

I have carefully read, understand and agree to the above statements.

Agree

Signature

Today's Date

2025 Blendville Camper Release Form

Parent Information

Camper Information

Medical Information

Agreements and Releases