Mountain Meadow Ranch Bible Camp
HC2 Box 148E
Payson, AZ 85541
mtnmeadowranch@theriver.com
928-478-4546
Dear Parent,
Thank you for registering your child for camp!
To assist in maintaining health and safety, all medications will be turned in to the nurse upon arrival at
camp. He or she will be responsible for dispensing these medications as instructed by the doctor. Please
make sure that all medication is in its own bottle (do not mix medications in the same bottle), labeled with
the camper’s name and proper instructions for dispensing. Permission is to be given for dispensing of overthe-counter medication. Aspirin, Tylenol and Ibuprophen are available at camp.
There is a snack bar available at camp. The prices range from $.75 - $1.50 for drinks and $.75-$1.50 for
snacks. We recommend bringing between $15.00 and $20.00 for the week.
If you would like to send your camper a letter, the camp address is: (you will want to mail it by Mon. in
order for your child to receive it)
Camper’s name
C/O Mountain Meadow Ranch
HC2 Box 148 E
Payson, AZ 85541
We do not have cell phone reception at camp. The camp telephone number is 928-478-4546. If there is an
emergency and you need to reach your camper, you can contact them through the office.
The camp session begins at 4:00pm on Saturday, May 30, registration will start at 2:00pm.
Camp is over at 2:30pm on June 4th. If your child will be returning home with someone other than his/her
parents or guardians, please fill out the parental permission slip included with the reservation packet.
What To Bring:
Please do not bring any electronics (Ipod, CD players, etc.) we want you to enjoy the great outdoors
(and interact with people around you J)
prescription medication
soap
deodorant
towels
pillow
flashlight
water bottle
toothbrush/paste
chap stick
washcloth
bible
camera
sunscreen
brush/comb
shampoo/conditioner
sleeping bag
notebook/pen
watch
clothes: shorts, t-shirts, tennis shoes, etc. (remember to pack some pants and sweatshirt, it can get cool at
night. Also keep in mind you’ll be outdoors having fun, try to bring clothes that won’t be ruined)
bathing suit for creek (girls please bring a one piece/modest suit or a T-shirt to wear over your suit)
We are excited about camp this summer! If you have any questions, please call or email.
Thanks
Bill Osier and Nicole Hunter
Directors
MMR Junior High Registration Form
Dates of Camp: May 30 – June 4, 2009
Name _______________________________ Date of Birth _____________
Telephone ______________________ Cell phone ____________________
Email ________________________________________________
Address ______________________________________________
City _____________________ State _________ Zip __________
Age ________ Grade completed in 2009 ____________
Shirt Size (Please circle) Youth - M L XL Adult - S M L XL
One cabin mate preference:_________________________
(Requests subject to discretion of Camp Director)
Parent’s name (PLEASE PRINT)__________________________
Parent’s signature ______________________________________
FEES: $210.00 if paid in full by May 17th
$260.00 if paid after May 17th
* $60.00 minimum deposit due upon registration
□ My child has special dietary needs: If checked, you must fill out Dietary
Restriction Form in the Registration packet
Please return completed reservation packet to:
Open Door Fellowship
8301 N 19th Ave
Phoenix, AZ 85021
Phone: 602.242.4414
CAMPER ACQUAINTANCE SHEET
Please complete the following information to help us get to know your Jr.
Higher:
Camper Name:______________________________________________
Who lives at home with the camper?
Parents/guardians:____________________________________________
Brothers:
______________□ Older □ Younger______________□ Older □ Younger
______________□ Older □ Younger______________□ Older □ Younger
Sisters:
______________□ Older □ Younger______________□ Older □ Younger
______________□ Older □ Younger______________□ Older □ Younger
Other (grandparent, etc.) _______________________________________
Anything you want us to know? (special needs/concerns etc.)
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
____________________________________________________________
Medical Information
To be filled out by parent/guardian of minors.
Name ______________________________ Birthday __________
Sex ______Age ____
Parent or Guardian __________________________________
Phone (_____)_________
Home address
___________________________________________________________
Business address ____________________________________
Phone (_____)_________
Second parent or guardian or emergency contact
________________________________
Home address_______________________________________
Phone (____)__________
Business address_____________________________________
Phone (____)__________
If not available in an emergency, notify
Name _____________________________________________
Phone (____)__________
Address______________________________________________________
Health history (check – give approximate dates)
Diseases:
Allergies:
Frequent ear infections ________
Hay fever____
Heart defect/disease_______ Mononucleosis_______ Asthma_________
Convulsions________
Chicken Pox________ Insect stings______
Diabetes ________
Measles ________ Penicillin _______
Bleeding/clotting disorders_______ German Measles ________
Other drugs_______
Hypertension________ Mumps ________ Poison Ivy_________
Peanut _______
Operations or serious injuries: (w/dates)
_______________________________________
_____________________________________________________________
__________
Disability or chronic recurring illness
_________________________________________
_____________________________________________________________
Dietary modifications
______________________________________________________
Current medications (send with
instructions)____________________________________
Other diseases or details of above
____________________________________________
Name of dentist/orthodontist _________________________
Phone(____)____________
Name of family physician ___________________________
Phone (____)____________
Date of last physical examination
___________________________________________
Do you have family/medical/hospital insurance _______________
If so indicate:
Carrier ________________________
Policy or Group # __________________________
Suggestions or health related information for camp person
________________________
_____________________________________________________________
__________
(For female) has this person menstruated? _____if not, has she been told
about it? _____
If so, is her menstrual history normal? _________________
Special consideration
______________________________________________________
_____________________________________________________________
__________
IMMUNIZATION HISTORY *
Required immunizations must be determined locally. Please record the date
(month and year) of basic immunizations and most recent boosters.
Vaccines
Year of basic
Year of last booster
immunization
Diphtheria
1.
1.
Pertussis (Whooping
2.
2.
cough DPT)
Tetanus
3.
or
Tetanus
Diphtheria TD
or
Tetanus
Oral Polio (Sabin)
TOPV
Injectable Polio (Salk)
Measles (hard measles,
red measles, Rubella)
Mumps
Rubella (German
measles, 3-day measles)
Other
Tuberculin test given
________________
(most recent)
*Important – this box must be completed for attendance
This health history is correct so far as I know, and the person herein
described has permission to engage in all prescribed camp activities except
as noted.
Emergency Authorization: I hereby give permission to the medical personnel
selected by the camp director to order X-rays, tests and treatment for my
child or myself. In the event I cannot be reached to authorize treatment in an
emergency, I hereby give permission to the physician selected by the camp
director to hospitalize, secure proper treatment for, and to order injection
and/or anesthesia and/or surgery for my child as named above or myself.
This form may be photocopied for use out of camp.
Signature of parent or guardian
______________________________________________
*If for religious reasons you cannot sign this, then the camp should be
contacted for a legal waiver that must be signed for attendance
DIETARY RESTRICTION FORM
(This form is only intended for specific food allergies, not general food
preferences)
Please be as specific as possible
Camper Name _________________________________________
Parent Name ________________________Phone # ____________
Email address ____________________Cell phone # ___________
Please list any medical dietary restrictions your child has:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_________
While we can make slight adjustments to our current menu, we cannot
substitute food items already on our menu. If your child requires special
food, it is the parent’s responsibility to provide that food and contact Bill
Osier @ 928-478-4546 prior to May 15, 2009 to discuss their special
circumstances.
----------------------------------------------------ACTIVITY RELEASE FORM
My child has permission to attend camp, participate in all activities on or off
campsite under the supervision of the camp staff, and receive emergency
medical care if necessary. Photographs may be taken for camp publicity.
While there is trained staff supervision at all times, there are many inherent
risks in activities and games that campers are involved in. Most activities are
conducted outdoors where there is a possibility of risk of physical injury or
harm.
I voluntarily choose to allow my child to participate in the camp experience
and assume the risk of injury or harm that could result from participation.
On my own behalf and that of my personal representative and heirs, I hereby
release Mountain Meadow Ranch Bible Camp, Inc. of all liability resulting
from any injury or harm while my child participates in any activity with
Mountain Meadow Ranch Junior High Camp.
I have read, understand and agree to the above:
My child can participate in any activity except:
_____________________________________________________________
_____________________________________________________________
____________________
PERMISSION TO RIDE
My child ________________________ has my permission to be released to,
and ride home with _________________.
Parent’s printed name: ________________________________
Signature: ___________________________ Date:__________