Camp Registration Form Please complete the form below for each child separately Camper’s Name * First Name Last Name Preferred Name Camper’s Date of Birth * MM DD YYYY Camper’s Sex * Male Female Camper’s T-shirt Size * Youth XS Youth S Youth M Youth L Youth XL School Year Entering in 2020 * Year 1 Year 2 Year 3 Year 4 Year 5 Year 6 Year 7 When did your camper first enter care? * How long has your camper been in your care? * Camper’s swimming ability Confident Needs Help I Don’t Know Sleeps with a night light Yes No Camper’s Emotional/Behavioural History Aggressiveness Often Sometimes Never Bedwetting Often Sometimes Never Biting Often Sometimes Never Eating Disorders Often Sometimes Never Hyperactive Often Sometimes Never Learning Disabilities Often Sometimes Never Lying Often Sometimes Never Nightmares/Terrors Often Sometimes Never Runs Away Often Sometimes Never Sexual Acting Out Often Sometimes Never Stealing Often Sometimes Never Tantrums Often Sometimes Never Withdrawn Often Sometimes Never Any further details or additional history Caregiver’s Name * First Name Last Name Mobile * Email Address * Home Address * I am a caregiver through Oranga Tamariki Open Home Foundation Homes of Hope Other Social Worker’s Name and Email * Social Worker’s Mobile * Physician’s Name * Physician’s Number Please Indicate Any Known Health Conditions/Allergies * *If your camper requires a special diet, please specify here. An additional fee of $50 will incur. Emergency Contact Name and Relationship * Emergency Contact Mobile * Thank you!