Youth Information

Youth Name *

First

Last

Youth Nick Name

What is the preference name to use.

What date are you attending?

3 day camp March 28 - 30
1 week camp March 28 - April 5

Child Sex

Male
Female

Youth Date of Birth *

Age of youth as of April 1, 2025

My youth has attended previous youth camp. If there are any changes, please fill appropriate questions . You may proceed to the cancellation agreement at the bottom of the page.

Youth General Medical History

Respiratory problems? Asthma? *

Yes
No

Gastrointestinal disturbances? *

Yes
No

Diabetes? *

Yes
No

Neurological problems? Epilepsy? *

Yes
No

Seizures? *

Yes
No

Dizziness or fainting episodes? *

Yes
No

Migraines? Medications, frequency, are they debilitating? *

Yes
No

Does your child see a medical or physical specialist of any kind? *

Yes
No

Any history of cardiac illness or significant risk factors? *

Yes
No

Knee, hip or ankle injuries (including sprains) and/or surgery within the past 5 years? *

Yes
No

Shoulder, arm and back injuries (including sprains) and/or surgery within the past 5 years? *

Yes
No

Any other joint problems? *

Yes
No

Head injury? *

Yes
No

Does your child have any physical, cognitive, sensory or emotional condition that would require a special teaching environment? *

Yes
No

Has your chlld had treatment, counselling or hospitalization with a mental health professional? *

Yes
No

Is camper allergic to any foods? *

Yes
No

Are there any dietary restrictions? Please specify *

None
Vegetarian
Vegan
Other

Has your child had any allergic reactions to insects, bee/wasp stings, or medications resulting in hives, swelling or difficulty breathing? *If appropriate please bring a personal supply of epinephrine, and know how to use it. *

Yes
No

Any other allergies? *

Yes
No

Does your child plan to take any prescription or non-prescription medications on the trip? *

Yes
No

Please explain any "Yes" above in detail

Parents Information

Child's Father Name *

First

Last

Child Father Phone number *

Child's Mother Name *

First

Last

Child's Mother Phone number *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

E-mail *

Emergency Contact Information ①. Do not use your spouse. We will try to contact both parents first.

First choice Parent/Guardian to be contacted in case of emergency (Full Name) *

First

Last

Relationship with the participant

Phone number *

I authorize this contact to pick up my child in emergency. *

Yes
No

Emergency Contact Information ②

Second choice Parent/Guardian to be contacted in case of emergency *

First

Last

Relationship with the participant

Phone number *

I authorize this contact to pick up my child in emergency. *

Yes
No

Authorization and Terms

Please carefully read the following text and check the terms below to confirm your acceptance to the terms of Moose Family Camp Resort

My child has my authorization to participate in the activities of the Moose Family Camp Resort programs. *

Yes
No

I guarantee that my child will listen to and carry out Moose Family Camp Resort and staff instructions and will not act irresponsibly, or beyond own ability. *

Yes
No

I allow taking photography and videos of my child that can be used for Moose Family Camp Resort advertising *

Yes
No

I authorized Moose Family Camp Resort to apply judgement in regards to medical assistance in the event of an accident, injury, or illness if they are unable to contact the parent/guardian. *

Yes
No

I shall accept full financial responsibility for any damage or loss of any equipment or items while it is within your child's possession or control *

Yes
No

I understand that the activity my child will participate during the camp can involve moderate physical, emotional and mental activity and that there are inherent risks that may result in injury or even death. I release Moose Family Camp Resort for any responsability in case of accident, illness, injury or even death during this camp. *

Yes
No

I understand that the activity this camper will participate during the camp can involve very strenuous physical, emotional and mental activity and that there are inherent risks that may result in injury or even death. I release Moose Family Camp Resort for any responsability in case of accident, illness, injury or even death during this camp. *

Yes
No

I understand that if my child show symptoms of being ill or having Covid-19, parents/guardian will be asked to pick-up the camper immediately. *

Yes
No

I will be paying via the following method *

Japanese Bank Transfer
Paypal
Navy Federal Bank Transfer

If you agree to these terms, you can pay via Japanese bank, Paypal or Navy Federal Credit Union. Let me know which one you prefer. Full payment is required within 3 business days. We will hold your reservations for 3 days.

Comment or Message

What would you like to have us do?

Cancellation Policy

I agree to abide by the cancellation policy
I disagree

30-16 days before the start of your program – 20% 15-7 days before the start of your program – 40% 6-2 days before the start of your program – 50% One day before the start of your program – 80% On the day of your program – 100%

I agree to the terms above and will use this as my signature. *

First

Last

Date Signed

Register your youth.

Youth Information

Youth General Medical History

Parents Information

Emergency Contact Information ①. Do not use your spouse. We will try to contact both parents first.

Emergency Contact Information ②

Authorization and Terms

Information

About Camp

Reservations

Activities

Information

Reservations

Activities

About Camp