2023 Camper Registration – Camp Conquest

We're looking forward to Camp Conquest 2023! Camp will be June 12-16, 2023 at Children's Harbor in Alexander City, Alabama. If you have questions, please contact information@kidscampconquest.com.

Step 1 of 6 - Camper Information

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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)

MM slash DD slash YYYY

Grade This Coming Fall(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Information

Please note that all information about camp, including forms that must be signed by a parent or legal guardian, will be sent to the email address provided here.

Parent/Guardian Name(Required)

First Last

Parent/Guardian Address(Required)

Same as Camper

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Primary Phone(Required)

Parent/Guardian Primary Phone Type(Required)

Cell

Home

Work

Other

Parent/Guardian Alternate Phone

Parent/Guardian Alternate Phone Type

Cell

Home

Work

Other

Parent/Guardian Email(Required)

Additional Contact

All campers need to have an additional contact in addition to the parent or guardian listed above. This may be an additional parent/guardian or a non-family emergency contact.

Additional Contact Type(Required)

Additional Parent/Guardian

Non-Family Emergency Contact

Additional Contact Name(Required)

First Last

Additional Contact Phone(Required)

Additional Contact Phone Type(Required)

Cell

Home

Work

Other

Additional Contact Email

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.

Camper History

Has your child experienced any significant life changes in the past year?

If yes, please describe.

Does your child have any fears or dislikes we should know about?

If yes, please describe.

Psychological/Social History

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

Has a primary complaint that is emotional or behavioral in nature

At any time has been on medication for ADD, ADHD, Depression, Impulse Control, or a Seizure Disorder

Has experienced any significant losses within the past year (i.e., the death of a family member, pet, divorce, etc.)

Has any destructive behaviors such as fire starting or cruelty to animals that have been brought to your attention

Basic Health/Behavioral History

Please choose which, if any, of the following areas the camper has health problems

Eyes (vision, night blindness, etc.)

Ears

Nose and throat

Teeth

Abdomen

Lungs (asthma, shortness of breath, etc.)

Heart defects

High blood pressure

Seizures

Bleeding disorders

Headaches or migraines

Nightmares or sleepwalking

Bedwetting

Hyperactivity

Head lice or bed bugs

Please describe any health problems indicated under basic health/behavioral history

Allergies

Bee/ant stings

Hay fever

Food allergies

Latex

Medications (please list below)

Other (describe below)

Allergy Details

Please describe the allergic reaction (rash, hives, wheezing, etc.) and any additional information such as what foods the camper is allergic to.

Does your child wear glasses or contacts?(Required)

Yes

Does your child have any dental appliances (braces, retainer, etc.)?(Required)

Yes

Please describe any special dietary needs.

Please describe any physical restrictions or limitations your child has that would affect their participation at camp.

Medication

Please list any medications your child will take while at camp. Click the + button to add additional rows. Any medications listed here should be brought by the camper to camp.

Medication Name

Dose

Frequency

Route (by mouth, cream, inhaler, etc.)

I give permission for Camp Conquest medical staff to dispense over-the-counter medication if needed for my child.(Required)

Over-the-counter medication may include, but is not limited to, Tylenol (acetaminophen), Advil (ibuprofen), Motrin (ibuprofen), Benadryl (diphenhydramine), anti-itch cream (hydrocortisone), or antacid. Please ensure that any medication allergies are described above in the allergies section. Only Camp Conquest medical staff (including nurses from Children's of Alabama and other medical professionals) are authorized to administer medication to campers.

Yes

Yes, with limitations (describe below)

Over-the-Counter Medication Limitations(Required)

Please describe any limitations on over-the-counter medications that can be administered to your child.

Females Only

Has the camper menstruated?(Required)

Yes

Has the camper been told about menstruation?(Required)

Yes

Is her menstrual history normal?(Required)

Yes

Has she used tampons in the past?(Required)

Yes

If cycle occurs at camp, do you give permission for her to use tampons?(Required)

Yes

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

How will your child be arriving and departing from camp?(Required)

My child will be leaving from Children's of Alabama to ride on the bus/van to camp

I will be taking my child directly to Children's Harbor in Alexander City, Alabama

Comments

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