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CAMP GAILOR-MAXON 2007

THIS WEB PAGE CONTAINS THE REGISTRATION, INSURANCE, AUTHORIZATIONS and HEALTH FORMS for CAMP GAILOR-MAXON 2007

(Please print FORMS. Once completed, mail to: CAMP GAILOR-MAXON, P. O. BOX 339, MONTEAGLE, TN 37356) This site also contains information about schedules, costs, transportation for your area, insurance, authorization forms and what to bring.

We have prepared for another great summer of fun, fellowship and faith-sharing at Camp Gailor-Maxon. This year promises to be one of the best ever!

Attendance is on a first-come, first-served basis, so we encourage you to register today. Please copy the following and mail it no later than APRIL 1, 2007.

* A completed REGISTRATION FORM, that can be copied below. A completed HEALTH FORM, that can be copied below. * If you plan to ride the Camp Bus to and/or from Camp: a completed TRANSPORTATION FORM, that is also below. When you mail in the completed forms a CHECK or MONEY ORDER, including any financial assistance from your church, for your camp fees, and transportation, if applicable. VISA , MasterCard and American Express are also accepted.

CAMP FEES: Camps I and II Camps III and IV

$526.00 $430.00

Mail copied and completed forms and fees to: Camp Gailor-Maxon, P. O. Box 339, Monteagle, TN 37356

If you have any questions, please contact: Pratt Paterson, Camp Director, DuBose Conference Center Phone: (931) 924-2353 Fax: (931) 924-2291

Email: Web: www.duboseconf.org

CAMP DATES 2007

CAMP I - Thursday, June 7th - Thursday June 14th (Rising 10th, 11th, 12th graders and entering college Freshmen)

CAMP II - Friday, June 15th - Friday June 22nd (Rising 8th and 9th graders)

CAMP III - Sunday, June 24th - Saturday June 30th (Rising 6th and 7th graders)

CAMP IV - Sunday, June 24th - Saturday June 30th (Rising 4th and 5th graders)

*NOTE: camps III and IV will be run simultaneously, sharing meals and worhsip.

* All campers must provide a copy of their HEALTH INSURANCE CARD. Parents and campers must sign the EXPECTATIONS AGREEMENT. NO AMNESTY will be extended to any camper who brings illicit drugs, alcohol or tobacco products in Camp. Any camper who violates this ban will be sent home immediately with his or her parents responsible for transportation.

WHAT to BRING to CAMP:

Blankets, Sheets or Sleeping Bag, Pillow, Daily clothes*, Pajamas, Towels, Toiletries, Swimsuit, Flashlight with extra batteries, Tennis shoes, Laundry bag, Caving/Hiking clothes, Rain gear or poncho, Sweater or jacket, Hiking shoes or boots, Daypack or book bag, and up to $ 20.00 for snacks.

*Pack one set of clothes for the banquet. Nothing too fancy - just a fun & festive outfit.

WHAT NOT to BRING to CAMP:

Tobacco products, Alcohol, Illicit drugs, Drug paraphernalia, Coolers, Pagers, Cell phone, Walkman, Electronic games, Clothing exhibiting disrespect, Clothing with objectionable logos or graphics, Clothing exhibiting poor taste, or clothing with tobacco/alcohol logos

BUS SCHEDULE and FEES:

* Important: Please be at the bus stop 30 minutes before departure and arrival times.

Memphis (Bus stop: Church of the Holy Communion) Bus departs first day at 9:00 a.m. CDT and returns last day at 5:00 p.m. (Round trip $ 125.00, One way $ 65.00)

Jackson (Bus stop: Comfort Inn (Hwy. 45 Bypass, Exit 80) Bus departs first day 11:00 a.m. CDT and returns last day at 3:00 p.m. (Round trip $ 110.00, One way $ 55.00)

Nashville (Bus stop: St. Georges Church) Bus departs the first day at 1:30 p.m. CDT and returns last day at 11:30 a.m. (Round trip $ 60.00, One way $ 35.00)

CAMP GAILOR-MAXON 2007 HEALTH FORM - Please complete and sign this form and return it with your registration form by April 1, 2007.

Camp Attending: (circle one) CAMP I CAMP II CAMP III CAMP IV

Camper's Name: (last) (first) (nickname)

Date of Birth: _________________ Sex: M F Age: _______________

Grade entering Fall 2006 (circle one) 4th 5th 6th 7th 8th 9th 10th 11th 12th freshman/other

Father's Name: ________________________Phone: home__________work__________cell___________

Mother's Name: _______________________Phone: home__________work__________cell____________

If not available in an emergency notify: Name: ___________________________Phone:home____________ work________________ Relationship to camper:____________________________________________

HEALTH HISTORY: Check all that apply with approximate dates:

ear infections_______ hay fever_______ chicken pox_______ rheumatic fever_______ seizures_______ diabetes_______ allergies_______ insect bite reaction_______ German measles_______ poison ivy_______ measles_______ mumps_______ ADHD_______ OTHER______________________________

Date of last tetanus booster (mandatory within past 10 years) ______________________________

Allergies to medication: penicillin_______ sulfa_______ others (please list)_____________________________________________________________________________

Operations or serious illnesses (dates) ___________________________________________________

Chronic or recurring illness/condition: ____________________________________________________

Disabilities: ________________________________________________________________________

List any additional health history or activity restrictions nurse should know about (example: food allergies, etc.) __________________________________________________________________________________

__________________________________________________________________________________

List all medications, including over-the-counter drugs camper will be bringing to camp, along with proper dosage instructions. Prescription drugs must be in the original containers. Note: ALL medications must be given to Camp Nurse at registration and will be kept in the Camp's Health Center.

Medication:__________________________________________________________________________

Dosage Instructions:____________________________________________________________________

Does the nurse have permission to dispense over-the-counter medication for headache/pain relief, coughs and colds, upset stomach or other minor health problems? YES __________ NO__________

INSURANCE: All campers must have health insurance. Enclose a copy of the front and back of your insurance card.

Camper's Insurance Provider: ____________________________Policy Number:______________________

Type of Provider: (circle one): PPO HMO Private Pay

Primary Insured's Name: _______________________________________________________

(Please notify camp if camper is exposed to any communicable disease during the three weeks prior to camp.)

AUTHORIZATION:

To the best of my knowledge, the health history provided is true and correct. I understand that payment for any medical treatment or prescription needed by my child is my sole responsibility.

My child has permission to engage in all available camp activities, including supervised use of ropes course, swimming pool and other off-campus trips and excursions.

In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by Camp Gailor-Maxon to hospitalize, secure proper treatment for, and to order the injection, anesthesia, or surgery for my child as named on this form.

Signature of Parent/Legal Guardian:_______________________________ DATE____/_____/_____

CAMP GAILOR-MAXON 2007 REGISTRATION FORM

(Check the session you will be attending:)

__________ CAMP I: June 7th-14th (Rising 10th, 11th, 12th grades and college freshman/other)

__________ CAMP II: June 15th-22nd (Rising 8th and 9th graders)

__________ CAMP III: June 24th-30th (Rising 6th and 7th graders)

__________ CAMP IV: June 24th-30th (Rising 4th and 5th graders)

Camper's Name: (First)____________________(M)_____________(LAST)______________________

Nickname or preferred name: __________________________ Sex: M F

Date of Birth: _____/_____/_____ E-mail address:__________________ T-Shirt Size: ________

Father's Name:___________________________Phone:home_______________work_______________

Mother's Name:_____________________________________________________________ __________________________Phone:home_______________work_______________

With which parent/guardian does camper live? ____________________________

Home Address: _______________________________________________________________________

_______________________________________________________________________

Camper's Church: ____________________________________ Diocese: ________________________

Priest's/Minister's Name: ______________________________ Phone: _________________________

If not an Episcopalian, give complete address of church camper attends:

______________________________________________________

(We can't promise, but if you would like to room with a friend, please list his/her name here:)

_____________________________________________________________________

REGISTRATION FEES: Payment for the full amount of your fee MUST accompany this registration form. Make checks payable to Camp Gailor-Maxon.

CAMP I and II CAMP III and IV

Fees: $526.00 $430.00

Diocesan subsidy:

Diocese West TN -105.00 (limited to 50 campers)

East & Middle TN -85.00

* If more than one child in a family is attending a camp session, each child after the first child can receive a $ 25.00 sibling discount.

List Children and Camp Attending: Child's Name: ____________________________Camp:_____

Child's Name: ______________________Camp:____ Child's Name:____________________ Camp:_____

MC/VISA/AMEX No. ______________________________________Expiration Date_____/_____/_____ Zip code_________________

Name on Card: _______________________________ Signature:_______________________________

*We want EVERY child to come to Camp. Please see your priest for scholarship assistance. If funds are not available from your church, please call (931) 924-2353.

TRANSPORTATION PERMISSION

Transportation to Camp: (circle one) West/Mid Diocese Bus Parents

Other: (How or with whom?) _____________________________________________________________

City leaving from and returning to: __________________________________Fee enclosed $_________

PARENT/GUARDIAN SIGNATURE: ____________________________________________________

TOTAL AMOUNT ENCLOSED:

CAMP FEE: ($526.00 or 430.00) $ ____________________

Less Diocesan Subsidy ($85.00/ $105.00 if applicable) - $ ___________________

Less Sibling Discount ($ 25.00 if applicable) - $ ___________________

Less Early Registration Discount

if paid by February 15th ($25.00 if applicable) - $_____________________

Transportation Fee (See bus schedule and fees above) $ _____________________

TOTAL: $ ____________________

EXPECTATIONS

* Campers will observe Christian virtues in all their decisions and actions. *Campers will stay on the DuBose grounds at all times, except for supervised excursions. *Campers will not use, possess illicit drugs, drug devices, alcohol or tobacco products. *Campers will not use or possess firearms, weapons or knives. * Campers will refrain from the use of profane or vulgar language. *Campers will respect other's property and persons. *Campers will be supportive of everyone in the community.

I have read the Camp Gailor-Maxon EXPECTATIONS and agree to uphold them while at Camp Gailor-Maxon.

Camper's SIGNATURE: _____________________________________________________________

I have read the Camp Gailor-Maxon EXPECTATIONS and agree to pick my child up within six hours, or pay for his/her transportation home if dismissal is necessary. I understand there will be no refund of camping fees upon dismissal.

Parent's Name: ________________________SIGNATURE:_________________________________

MAIL FORMS TO: CAMP GAILOR-MAXON, P. O. BOX 339, 635 College Street, Monteagle, TN 37356