* Camper's Name
This is used for reporting purposes only and will not be connected to the child's name.
Native Hawaiin/Other Pacific Islander
American Native/Alaska Native
Two or more races
Primary Emergency Contact & Relation to Camper
Primary Emergency Contact Phone
* Primary Emergency Contact Phone
Alternate Emergency Contact & Relation to Camper
Alternate Emergency Contact Phone
* Alternate Emergency Contact Phone
Name of Family Doctor
Family Doctor Phone
* Family Doctor Phone
Insurance Company & Policy Number
Name of Primary Insured & Relation to Camper
Date of Last Tetanus Shot
* Date of Last Tetanus Shot
If you checked, "yes," to any of the above health and medical concerns, please provide any necessary information.
Please call me before giving my child any over the counter medication.
I understand participants will be supervised and that, if serious illness or injury develops, medical and/or hospital care will be given. I hereby give my permission to the attending physician to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child and affirm that the information set forth in the Health Form section is true and correct to the best of my knowledge.
Photography of my child
My child may be photographed.
My child may only be photographed in group pictures.
My child may NOT be photographed.
Do you require financial assistance to attend camp?
Yes, I would like a full scholarship for this camp.
I would like a partial scholarship for this camp.
I am a Ranger scholar.
No, I do not require a scholarship for this camper.
I hereby release Rock Springs 4-H Center, and the Cabins4Kids Organization, officers and employees, from all claims, demands, and causes of action of any kind, including claims of negligence, which may arise from participation of my minor child in any Cabins4Kids sponsored activity, and this release is specifically granted in consideration of the services, programs and activities, including activities that involve horses, provided by the Rock Springs 4-H Center and being allowed to participate.
Youth Code of Conduct
As a participant in Cabins4Kids events, you have the responsibility of representing Cabins4Kids to the public. You are expected to conduct yourself in a manner that will bring honor to you, your family, and Cabins4Kids. To do that you must:
1) Attend all sessions in the planned program. If you are unable to attend please tell the adult in charge.
2) Follow hours and room rules established before the event begins and you are responsible to know the rules for each event.
3) Dress appropriately for each event. The adults in charge should have guidelines to help you.
4) Be responsible to know and use language and manners appropriate for Cabins4Kids.
5) Be in the assigned program area (for example: dorms, cabins, motels, etc.) at all times.
6) Know that the use of tobacco, alcohol and nonprescribed drugs is illegal and prohibited at Cabins4Kids events.
7) Model respect for other persons, facilities and vehicles. You will be personally responsible for any damage caused as a result of your behavior.
8) Help other members in your group have a pleasant experience by making every attempt to include all participants in activities.
9) Know that harassment of any type is illegal and prohibited at all Cabins4Kids events.
10) By typing the camper's name below I, and my camper, acknowledge that we have read the Cabins4Kids Youth Code of Conduct and agree to live up to the expectations. We realize that the failure to do so could result in loss of privileges during the event and/or in the future.
If you selected a partial scholarship, please let us know how much your family is able to contribute.