2022 Leader in Training Adventure Retreat Registration

New in 2022, we're excited to offer a Leader in Training Adventure Retreat! We'll be back at Children's Harbor in Alexander City, Alabama August 26-28. If you have questions, please contact information@kidscampconquest.com.

Step 1 of 6 - Camper Information

Camper Information

Camper's Full Name(Required)

First Middle Last

Camper's Nickname

Camper's Gender(Required)

Female

Male

Camper's Date of Birth(Required)

Grade This Fall(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Home Phone(Required)

Cell Phone(Required)

Email(Required)

Did you attend Camp Conquest in June 2022?(Required)

Yes

Please check which, if any, of the following has changed since June.

Parent/Guardian or Emergency Contact Information

Insurance Information

Camper History (including social and medical history)

Burn History (including rehabilitation details)

Parent/Guardian Information

Please provide contact information for a parent or guardian and either an additional parent or guardian or an emergency contact. Information about camp will be sent to the email address provided for parent/guardian 1.

Parent/Guardian 1

Parent/Guardian 1 Name(Required)

First Last

Parent/Guardian 1 Address(Required)

Same as Camper

Street Address Address Line 2 City State ZIP Code

Parent/Guardian 1 Home Phone(Required)

Parent/Guardian 1 Cell Phone(Required)

Parent/Guardian 1 Email(Required)

Additional Contact(Required)

All campers need to have an additional contact in addition to the parent or guardian listed above. Please choose whether you would like to list an additional parent or guardian or a non-family emergency contact.

Additional Parent/Guardian

Non-Family Emergency Contact

Parent/Guardian 2

Parent/Guardian 2 Name(Required)

First Last

Parent/Guardian 2 Address(Required)

Same as Camper

Street Address Address Line 2 City State ZIP Code

Parent/Guardian 2 Home Phone(Required)

Parent/Guardian 2 Cell Phone(Required)

Parent/Guardian 2 Email(Required)

Emergency Contact

Emergency Contact Name(Required)

First Last

Emergency Contact Primary Phone(Required)

Emergency Contact Alternate Phone

Please choose an option(Required)

Enter insurance information manually

Upload a picture of insurance card

Name of Carrier(Required)

Name of Insured(Required)

Policy Number(Required)

Group Number(Required)

Insurance Card(Required)

Please upload a picture of both the front and back of the insurance card.

Drop files here or

Max. file size: 100 MB.

Burn History

Date of Burn(Required)

Month and year

Age at Time of Burn(Required)

Please enter a number greater than or equal to 0.

Percentage of Burn(Required)

Please enter a number from 0 to 100.

Place of Treatment(Required)

Number of Days Hospitalized(Required)

Note that campers must have been hospitalized for at least 5 days to be eligible to attend Camp Conquest.

Please enter a number greater than or equal to 5.

Body Area(s) Burned(Required)

How was camper burned?(Required)

Rehabilitation Details

Rehabilitation Needs

Please choose which, if any, of the following apply to your child

Wears pressure garments

Will use lotion or cream for scar massage while at camp

Wears splints or orthopedic devices

Is currently receiving physical or occupational therapy

Will require wound care while at camp not listed here (please describe below)

Rehabilitation Needs Details

Please provide any additional details related to your child's rehabilitation needs

Concerns for Medical Staff

Please describe any additional concerns, if any, you would like the camp medical staff to address

Transportation To/From Camp

For more details about transportation, click here.

How will you/your child be ARRIVING at camp?(Required)

I/my child will take the bus from Children's of Alabama

I/my child will be dropped off directly at Children's Harbor in Alexander City, Alabama on FRIDAY EVENING

I/my child will be dropped off directly at Children's Harbor in Alexander City, Alabama on SATURDAY MORNING

How will you/your child be DEPARTING from camp on Sunday afternoon?(Required)

I/my child will take the bus to Children's of Alabama

I/my child will be picked up directly from Children's Harbor in Alexander City, Alabama

Name

This field is for validation purposes and should be left unchanged.

Camper Information

Parent/Guardian Information

Parent/Guardian 1

Parent/Guardian 2

Emergency Contact

Camper History

Females Only

Burn History

Rehabilitation Details

Transportation To/From Camp