2024 Camper Registration We’re looking forward to Camp Conquest 2024! Camp will be June 10-14, 2024 at Children’s Harbor in Alexander City, Alabama. If you have questions, please contact information@kidscampconquest.com. Step 1 of 6 – Camper Information 16% Camper InformationCamper'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)23456789101112Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian InformationPlease 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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian Primary Phone(Required)Parent/Guardian Primary Phone Type(Required) Cell Home Work Other Parent/Guardian Alternate PhoneParent/Guardian Alternate Phone Type Cell Home Work Other Parent/Guardian Email(Required) Additional ContactAll 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 Select files Max. file size: 100 MB. Camper HistoryHas 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 HistoryPlease 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 HistoryPlease 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 historyAllergies Bee/ant stings Hay fever Food allergies Latex Medications (please list below) Other (describe below) Allergy DetailsPlease 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 No Does your child have any dental appliances (braces, retainer, etc.)?(Required) Yes No Please describe any special dietary needs.Please describe any physical restrictions or limitations your child has that would affect their participation at camp.MedicationPlease 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 NameDoseFrequencyRoute (by mouth, cream, inhaler, etc.) Add RemoveI 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) No Over-the-Counter Medication Limitations(Required)Please describe any limitations on over-the-counter medications that can be administered to your child.Females OnlyHas the camper menstruated?(Required) Yes No Has the camper been told about menstruation?(Required) Yes No Is her menstrual history normal?(Required) Yes No Has she used tampons in the past?(Required) Yes No If cycle occurs at camp, do you give permission for her to use tampons?(Required) Yes No Burn HistoryDate 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 DetailsRehabilitation NeedsPlease 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 DetailsPlease provide any additional details related to your child’s rehabilitation needsConcerns for Medical StaffPlease describe any additional concerns, if any, you would like the camp medical staff to address Transportation To/From CampHow 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 CAPTCHA
