CAMPS KATERI TEKAKWITHA 2010

REGISTRATION FOR YOUTH RESIDENTIAL AND FAMILY CAMP

CAMP TEKAKWITHA, THE YOUTH ALL CAMPS ARE HELD AT:
OFFICE AND PRAIRIE STAR RANCH Prairie Star Ranch
ARE FUNDED IN PART BY THE 1124 California Road
ARCHBISHOP’S CALL TO SHARE. Williamsburg, Kansas 66095

Mail Registration to: Youth Office 12615 Parallel Pkwy. Kansas City, KS. 66109
Camps Kateri Camps Tekakwitha Tekakwitha & X-Treme Family Camp
entering 5th & 6th grades entering 7th & 8th grades Entering 9th—12th graders
July 16-18
Term 1 June 1-3 $230 Term 1 June 7-12 $370 Camp Tekakwitha Ages newborn—2 Free
Term 2 June 4-6 $230 Term 2 June 14-19 $370 June 21-26 $380 (no babysitting provided)
Term 3 June 28-30 $230 Term 3 July 10-15 $370 Tekakwitha-Extreme
Term 4 July 6-8 $230 Term 4 July 19-24 $370 July 26-Aug 3 $430 Ages 2 years and Up $125

GENERAL INFO SAFETY

Prairie Star Ranch (PSR) is the beautiful, premium facility that
hosts Camps Kateri Tekakwitha. The camps offer horseback
riding, high ropes challenge, canoeing, hiking, orienteering, rock
climbing, rappelling, basketball, soccer, swimming, group party
games, archery, volleyball, mountain biking, mountain boarding,
outdoor camping, softball, numerous Catholic prayer and
sacramental experiences, and other outdoor camp activities.
PSR’s cabins are air conditioned and heated as needed.
Camp is a powerful spiritual experience that campers look
forward to. Please reinforce the following policy protecting the
high priority of faith development. It is assumed that all campers
are staying for the entire session. Leaving and returning during a
session is not permitted. Each camper is vital to the synergy of the
cabin and camp dynamics. Please choose a camp session that
does not conflict with sports or other engagements.
As parents, we understand that it is hard to leave your children,
but we can assure you that our trained staff will make every effort
to ensure the safety and well-being of your child during his or her
stay. Our staff goes through a thorough screening process,
receives training in their areas of responsibility, and they are
backed up by a professional administrative team that evaluates
and educates them throughout the summer. All staff are Virtus
trained. A 1:8 counselor-to-camper ratio is used. Specific
procedures are in place for campers to easily communicate con-
cerns directly to the camp directors.
To ensure the integrity of the camp, staff members will check
all baggage as you arrive. Food, gum, candy, jewelry, cell
phones, MP3 players, and valuable items are not allowed.
If a family emergency occurs, or special circumstances
require you to check on your child during camp, call Camp
Tekakwitha office at 785-746-5693.

ALL INTERNET AND MAIL APPLICANTS MUST FILL OUT THE ENCLOSED CAMP REGISTRATION FORM.
 Arrival/Departure Times
June
• Kateri 1 June 1 arrive 9 a.m.; June 3 closing 7-8:00 p.m.
• Kateri 2 June 4 arrive 9 a.m.; June 6 closing 7-8:00 p.m.
• Jr. High 1 June 7 arrive 9 a.m.; June 12 closing 9:30-10:30 a.m.
• Jr. High 2 June 14 arrive 9 a.m.; June 9 closing 9:30-10:30 a.m
• Sr. High June 21 arrive 9 a.m.; June 26 closing 9:30 –10:30 a.m.
• Kateri 3 June 28 arrive 9 a.m.; June 30 closing 7-8:00 p.m.
July-Aug.
• Kateri 4 July 6 arrive 9 a.m.; July 8 closing 7-8:00 p.m.
• Jr. High 3 July 10 arrive 9 a.m.; July 15 closing 9:30-10:30 a.m.
• Family July 16 arrive 10:30 a.m.:July 18 closing 3:00p.m.
• Jr. High 4 July 19 arrive 9 a.m.; July 24 closing 9:30-10:30 a.m.
• T-Extreme July 26 arrive 9a.m.; closing Aug 3 9:30 –10:30 a.m.
Arrive 20-30 min. prior to closing for luggage pickup. Please
honor the times listed above. Late arrival and early departures are
strongly discouraged as welcome and closure are important parts
of the total experience. In the event that a late arrival or early
departure is necessary, it must be discussed with the camp
director a.s.a.p. Your child will be permitted to ride home from
camp ONLY with the persons listed on the registration form.
Changing or adding names to the form maybe done at the time of
check-in. Your signature is necessary to allow your child to ride
home with anyone other than his/her parents or guardians. For
safety reasons, campers are not permitted to drive themselves to
camp.
CLOSING EVENT
The concluding program is VERY SPECIAL to share
with your children. Please make sure you reserve
this time for your child! The closing program will
begin promptly as scheduled.
SCHOLARSHIP APPLICATIONS
Scholarship forms are available & requests are due January 20. If
you miss this deadline, still apply in case funds become available.
HOW TO REGISTER
REGISTER 7th thru 12th GRADE CAMPERS ON FEBRUARY 1st.
REGISTER 5th & 6th GRADE CAMPERS ON FEBUARY 8th.
♦ Online Registration. To register go to www.archkck.org and
f ollow registration instructions. If you wish to become a member of
our on-line community, go to “Login” and “Create a New Account”.
Membership will insure your receipt of camp updates via e-mail.
(Spam blockers will occasionally block the website e-mail, please
check your settings.)
♦ Additionally, you must download a hard copy of the Campers’
Registration & Health Form and mail to the Youth Office to complete
the registration process. Your online reservation will be matched to
your hard copy Registration & Health Form upon receipt. U.S.
Mail Registration. Registrations must be postmarked no earlier
than Feb 1 or Feb 8. Registrations postmarked prior to Feb 1 or
Feb 8 will be returned. No hand delivered registrations will be
accepted. Hundreds of registrations are received via mail during
the first few days of registration. Mailed forms are sorted at random
by postmarked date as they are received in the daily mail.
♦ Many camp spots are available for registrations received through
the mail; however, we encourage use of our online registration
system. Spots are reserved on a first-come, first-serve basis.
♦ Each camper will need a completed Registration & Health Form, a
photocopy of health insurance card, a wallet-size photo of camper
(will not be returned), and a non-refundable $100 deposit. Final
balances are due May 15 thru online or check payment options.
♦ Each camper will need to bring to camp on opening day, the
Health Exam Waiver (one page Archkck form) or a sports
physical, not more than 24 months old, signed by a medical
professional. The Health Exam Waiver is attached to this packet.
INCLUDED IN THE COST OF CAMP
The camp fee covers all necessary expenses. Food, snacks, lodging,
activities, materials, etc. are provided. Camp clothing will be available to
purchase for additional cost at check in on the first day of camp.
 PACKING LIST PACKING RESTRICTIONS/DRESS CODE
MAKE SURE TO BRING Our camps require an abundance of physical activity. We
WATER BOTTLE want to focus on deepening our faith and enjoying our outdoor
Pillow adventure, and not on one another’s clothes or lost possessions. It
Sleeping Bag or Bedding is important to pack clothes that will be comfortable, safe, and
Bug & Tick Repellant modest (no tank tops or bare midriffs, please) during the athletic
Sunscreen activities. Manufactured sleeveless shirts are allowed. We
Sweatshirt or Light Jacket require a minimum of a 2” inseam on all shorts. Clothing that
Towels & Washcloths promotes non-Christian values will not be permitted. Cologne,
Toiletries make up, and jewelry need to be kept to a minimum.
Flashlight All baggage is thoroughly checked upon arrival to ensure a
Swimsuit (one piece) fun, spirit-filled, and safe camping experience for all.
Jeans for horseback riding Good hygiene is also important; deodorant use and showering
Seat Cushion (for outside) are strongly encouraged.
Swimming Shoes (no flip flops) All meals and snacks are provided by the camp. No outside
Tennis shoes (extra pair may be used for swimming shoes) food may be brought in, unless special dietary needs must be
Shoes or boots with a firm hard covering and heels for riding met. Pre-approval is required.
(Tennis shoes may not be worn for horseback riding) Cabins are air conditioned when conditions dictate. Attic fans
MODEST comfortable casual clothes are installed in the cabins, but a small fan may be desirable.
1 package of note cards (3x5) Thank you for your understanding and support.
Spiral notebook & pen
15 identical BEADS with a hole large enough for yarn
Bible (Old & New Testaments) NAB version is the norm at camp
FAMILY CAMP PARTICIPANTS WILL BE MAILED A SPECIAL PACKING LIST
CABIN MATES
OPTIONAL ITEMS At camp (not before) campers are notified of their cabin
Small Fan Disposable Camera(s) assignment. Roommate requests can be made
Shower Shoes Stationary, pens & stamps (No stamps sold.) on the Health Form. Under the following
conditions, roommates requests are considered:
DO NOT BRING THESE ITEMS 1. One roommate request per camper.
NO FOOD, MAGAZINES,CANDY OR GUM 2. Camper A must request Camper B and
NO WEAPONS OR FIREWORKS Camper B must request Camper A.
NO VALUABLE ITEMS 3. Registrations MUST be mailed together,
NO KNIVES OR TOOLS even if you register on-line.
NO WIRELESS PHONES, PAGERS, ETC. Please remember, the spiritual experience of camp is
CROCS FOR SHOWER SHOES ONLY our #1 priority.
Please use the following numbers to answer your questions: CHARGES/REFUNDS
Registration Questions (Calls returned in 24-48 hours)
Camp Info Line 913-647-3054 or jenniferarchkck@sunflower.com A $100 non-refundable deposit is due with each registration.
Camp Policies/Camp Activities The balance is due May 15. Registrations submitted after May 15
Shawn Madden 785-746-5693 or PrairieStarRanch@gmail.com need to include full payment. If cancellation becomes necessary,
Donations/Camp Safety and if your camper’s spot can be filled, you will receive a refund
Dana Nearmyer 913-647-0331 or youth@archkck.org, (June 1-Aug 8) 785-746-5693 minus your deposit. Refund claims must occur within one month
To Download Forms and Brochures: go to www.archkck.org, of the camp session closing. If a camper is wait listed and does
Mary Rukavina 913 647-0373 or youthsec@archkck.org not get into a camp, the deposit check is voided and destroyed.

road). Proceed approximately ¾ mile. Prairie Star

drive south, away from gas station, 8/10 of a mile to

Ranch is on the right (large stones mark entrance).

William Street. (Williamsburg’s main street). Turn
VISITORS/USE OF PHONE

From I-35, take the Williamsburg exit (# 170) and

mile. Turn left (South) on California Road (gravel

right (west) on William Street and drive 1/10 of a
Campers do not have access to phones. Camp directors will
monitor any need for campers to use the phone. Parents may call
office personnel to check on their child’s well being.
We strongly encourage parents to write your
child and place letters in inner-camp mail on

DIRECTIONS
opening day of camp; they really do enjoy getting
your letters. Letters that are received, via the mail,
after a camper has left, will be shredded. Only
authorized guests are allowed on the premises
during camp sessions. No pets allowed.

SPIRITUAL FORMATION
Camps Kateri Tekakwitha combine demanding outdoor activities
with powerful spiritual instruction bringing about a unique
encounter with God. Although our adventure activities are
memorable, often the love that campers experience through
prayer is what kids remember most. Your child will have the
opportunity to experience different forms of prayer during camp.
Adoration, Reconciliation, veneration of the cross, rosaries,
litanies, Mass, informal group prayer and individual
reflection are among the many styles of prayer we
practice here. These prayer experiences will have a
lasting impact on campers ONLY IF they are lived
out and continued. We encourage you to pray for
your children during camp and with them after
camp.
 Registration Instruction Overview
Timeline and Methods of Registration:
♦ Registration begins for 7th thru 12th grade campers on February 1, 2010 (Online 9:00 a.m.).
♦ Registration begins for 5th & 6th grade campers on February 8, 2010 (Online 9:00 a.m.).
♦ Registrations postmarked and/or received prior to February 1st for 7th thru 12th grade campers will be
returned. Registration postmarked and/or received prior to February 8th for 5th & 6th grade campers will be
returned. Please respect the February 1st and February 8th registration dates or this could cause your child to
lose his or her place! NO HAND-DELIVERED REGISTRATIONS WILL BE ACCEPTED.
♦ Camp sessions fill very quickly! Spots are reserved on a first-come, first-serve basis. Many camp spots are
available for registrations received through the mail. However, we encourage the use of our online registration
system. Using online registration will give you instant confirmation. Mail applicants will receive a
confirmation or wait list letter three weeks after registration. Final balances are due May 15, thru online or
check payment options.
♦ To register go to www.archkck.org and follow registration instructions. If you wish to become a member of
our on-line community, go to “Login” and “Create a New Account”. Membership will insure your receipt of
camp updates via e-mail.
♦ Registrations are not accepted without completed health forms, a photocopy of health insurance card,
wallet size photo of camper (will not be returned) and a non-refundable and non-transferable deposit amount
of $100. Each camper will need to bring to camp on opening day, the Health Exam Waiver (one page Archkck
form) or a sports physical, not more than 24 months old, signed by a licensed medical professional.
Please use the following numbers to answer your questions:
Registration Questions—Camp Info Line 913-647-3054 or jenniferarchkck@sunflower.com
Camp Policies/Camp Activities—Shawn Madden 785-746-5693 or PrairieStarRanch@gmail.com
Donations/Camp Safety—Dana Nearmyer 913-647-0331 or youth@archkck.org, (June 1-Aug 3) 785-746-5693
Please give us 24-48 hours to return your calls before calling again.
To Download Forms and Brochures go to www.archkck.org. Camp brochure includes policies and procedures,
arrival and departure times, directions, packing list, etc. Before you call, please check the website for the
answers to your questions.

Family Camp:
The information in this packet does not completely explain family camp. Family camp is an extraordinary
experienceabout which we love to spread the word. All families have their own “cabin.” All cabins are
air-conditioned. Each family has its own wait staff. Meals are really fun. Tables are cleared by your
personal wait staff. The price is all-inclusive, (no tipping please). Family camp brings families closer
together. Teens, toddlers, parents and grandparents love family camp. Call Dana Nearmyer at 913-647-0331
or youth@archkck.org (June 1-Aug 8) 785-746-5693 if you have any questions about family camp.

Youth Residential Camp Scholarships are available. Applications are due January 20, 2010.
If you miss the scholarship deadline, you may mail your application late. In the event additional funds are
donated, additional applications will be considered during the registration process. For specific questions
regarding your application submission, e-mail jenniferarchkck@sunflower.com.

www.archkck.org register on-line!

INTERNET AND MAIL APPLICANTS MUST ALL TURN IN THE ENCLOSED

REGISTRATION FORMS A.S.A.P. AFTER FEB 1, 2010 or FEB. 8, 2010
 CAMPS KATERI TEKAKWITHA 2010
All Camps are Held at:
PRAIRIE STAR RANCH
1124 California Road
Williamsburg, Kansas 66095

HEALTH EXAM WAIVER

CAMPER’S NAME:_________________________________________________
CAMPER’S ADDRESS:______________________________________________
CAMP SESSION/DATE:_____________________________________________
CAMPER’S GRADE FALL 2010:______________________________________

_________________________________ (camper) is physically fit to attend camp at Camps Kateri

Tekakwitha. The date of last exam was _________________________ (within the past 24 months). Please list
current ongoing treatments or medications, if
any.____________________________________________________________________.

Date_________________. ___________________________________
Licensed Medical Professional

Date_________________. ___________________________________
Parent or Guardian

The camps offer horseback riding, high ropes challenge, canoeing, hiking, orienteering, rock climbing,
rappelling, basketball, soccer, swimming, group party games, archery, volleyball, mountain biking, mountain
boarding, outdoor camping, softball, numerous Catholic prayer and sacramental experiences, and other
outdoor camp activities. Not all activites will be available for 5th & 6th grade campers. No camper will be
forced to participate in any activity at which they are uncomfortable.

THIS FORM SHOULD BE BROUGHT TO CAMP ON OPENING DAY.

DO NOT MAIL.
 CAMPS KATERI TEKAKWITHA
TEKAKWITHA2004
2010
Registration Address: Camp Tekakwitha
Archdiocese of KC in KS


12615 Parallel Parkway


Kansas City, KS 66109
@ Prairie
Camp Address: Prairie Star Ranch
1124 California Road, Ranch
StarWilliamsburg, Kansas 66095
Tel 785/746-5693
Please mail to: Camp Tekakwitha
Archdiocese of KC in KS
12615 Parallel Parkway
Kansas City, KS 66109

REGISTRATION & HEALTH FORM- FOR ALLYOUTH CAMPS

Very Important! Have you already reserved a spot online? YES/NO.
Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___
Grade in upcoming year ___________ MALE FEMALE Phone # (_____)________________
Street Address _______________________________________Parent Email_____________________
City ___________________________________________ State ____________ Zip ______________
Parish __________________________________________ Parish City__________________________
Mother’s Name _________________________ Phone (Day) (____)________ (Evening) (____)_________
Mother’s Complete Address (if different than camper) ____________________________________________
Father’s Name __________________________ Phone (Day) (____)________ (Evening) (____)_________
Father’s Complete Address (if different than camper) _____________________________________________
Emergency contact (in case you can’t be reached) _________________________________________________
Phone # (____)_____________________ Relation to camper _________________________________
One cabin mate, of same gender and grade, request is permitted _______________________________
(See camp packet for cabinmate request details)
Emergency numbers (cell phone numbers) for parents during camp week ________________________
___________________________________________________________________________________

List Choices in Order From First To Last (1,2,3,4,).

Please note “N/A” for sessions that your camper is Not Available to attend.

Camps Kateri Camps Tekakwitha

Entering 5th & 6th grades Fall 2010 Entering 7th & 8th grades Fall 2010
Term 1 June 1-3 $230______ Term 1 June 7-12 $370_______
Term 2 June 4-6 $230_______ Term 2 June 14-19 $370_______
Term 3 June 28-30 $230_______ Term 3 July 10-15 $370_______
Term 4 July 6-8 $230______ Term 4 July 19-24 $370_______

Please see brochure for arrival/departure Please see brochure for arrival/departure times
times PRIOR TO registering your child PRIOR TO registering your child.

Tekakwitha & X-Treme Family Camp

Entering 9th—12th grades in Fall 2010
(including graduating seniors) July 16-18
Camp Tekakwitha Ages newborn—2 Free
June 21-26 $380__________ (no babysitting provided)

Tekakwitha-X-Treme Ages 2 years and Up $125

July 26-Aug 3 $430________
Please see brochure for arrival/departure times SEE FAMILY CAMP FORM TO SIGN UP
PRIOR TO registering your child.
Page 1 of 3 Youth Residential Camp
 Please note there are 4 required signatures!!!
Is this participant in general good health and able to participate in normal camp activities? Yes _____ No _____

Date of most recent physical examination by a licensed medical doctor. Date: ____/____/____
(If upcoming appointment set, please note:_________________________________________________________.)

!!!! VERY IMPORTANT !!!!

♦ You MUST have written verification FROM LICENSED MEDICAL PERSONNEL that the camper has had a
health examination during the past 24 months and the record SHOULD INCLUDE: any physical condition
requiring restrictions on participation in camp and descriptions thereof, date of exam, and current on-going
treatments or medications, and the record should be signed and dated. Please fill out our Health Exam Waiver
(one page Archkck form) or a sports physical, not more than 24 months old, signed by a licensed medical
professional. THIS INFORMATION MUST BE BROUGHT WITH YOU THE FIRST DAY OF CAMP.
PLEASE DO NOT MAIL. (This Information Required by American Camping Association). (Health Exam
Waiver form attached to camp packet.)

Doctor’s Name and Clinic:______________________________________________________________________

Doctor’s Full Address: _________________________________________________________________________
Doctor’s Phone #: (_____)____________________
Are all immunizations up to date? Yes _____ No _____ (If upcoming appointment set, please
note:__________________.)
Date of last tetanus booster: ____/____/____ (Tetanus Boosters are Required Every 10 years.)
If any are not up to date please list them.
_____________________________________________________________________

MEDICATION
Allergies/Conditions: (Check if participant is allergic to any listed or has any of the following conditions)
Bee Stings ______ Poison Ivy ______ Asthma ______ Fainting ______
Penicillin ______ Sulfa ______ Seizures ______ Hay Fever ______
Latex________ First Aid Antiseptics____ Antibiotics _____ Other ________

If any of the above were checked yes, please submit a statement in space provided below of how the child has been
treated and with what medications. Please also list (use back of page 3 if necessary):
1. Any operations or serious injury in the past two years.
2. Medical limitations or needs that we need to be aware of.
3. Any limitations or needs (learning styles, family situations, custody arrangements, etc.)

If your son/daughter will be taking over-the-counter or prescription medications while at camp please list ALL
medications (over-the-counter AND prescriptions) name, dosage and frequency on a 3x5 card and place in a ziploc
bag with your child’s name on it along with the medications. Prescription medications must be in original container.
Any changes in medication must be reported when registering at camp. No medication, even Tylenol, will be
dispensed to your child other than what you provide, unless an emergency situation dictates. Please send Tylenol if
you child is susceptible to headaches.

The ziploc bag, and all other medication, prescription and non-prescription medication will be collected at
registration and dispensed by the assigned team person. Youth may not keep ANY medication.

#1 Signature _________________________________________________________ Date ________________

(Parent or Guardian please sign even if child not on medication)
Page 2 of 3 Youth Residential Camp
 Please list any special dietary needs for your child. ___________________________________________________
____________________________________________________________________________________________
Notify the director if this child is exposed to any communicable disease during the three weeks prior to camp

Parents will be notified of fever, vomiting, intense homesickness or anxiety, areas that require gauze bandaging, x-rays or
stitching, and of other situations of concern to determine the course of action to be taken.
In case of medical emergency, I understand that every effort will be made to contact parents or guardians of camper. In the
event that I cannot be reached, I hereby request and give permission to the physician selected by the Camp to hospitalize,
secure proper treatment for, and to order anesthesia or surgery for my child, as named herein. In signing this health form, I
hereby certify that the information is correct and give permission for the release of medical records to an attending physician
in case of illness or emergency. I request that my child be transported to seek needed medical attention.

#2 Parent or Guardian Signature ______________________________________________ Date _______________

Health Insurance Company ______________________________________________________________________

Health Insurance Policy # _______________________________________________________________________
Primary Health Insurance holder, name and Social Security # ________________________________________

A Photocopy of the Primary Health Insurance card MUST be submitted with this form.

I request that my child ____________________ be allowed to participate in the camp activities at Camp Kateri or Camp
Tekakwitha at the Archdiocesan Camp in Williamsburg, KS. I hereby release and indemnify the Archdiocese of Kansas City
in Kansas, its staff, and volunteers from any liability arising from claims of any kind or nature whatsoever from my child’s
participation in this program. The activities may include horseback riding, high ropes challenge, power kiting, stunt kiting,
canoeing, hiking, orienteering, rock climbing, rappelling, basketball, soccer, swimming, technical tree climbing, group party
games, archery, volleyball, mountain biking, mountain boarding, outdoor camping, softball, numerous Catholic prayer
experiences, and other outdoor camp activities.

#3 Parent or Guardian Signature__________________________________________ Date ________________

Full Address _________________________________________________________________________________
Signature of Custodial Parent (if applicable) ________________________________________________________

PHOTO RELEASE
I hereby authorize the Archdiocese Of Kansas City in Kansas, and its agents to utilize my child’s photographic image for the
specific purpose of publication of the Archdiocese Of Kansas City in Kansas events (including promotional materials). In
giving my consent, I hereby release and hold harmless the Archdiocese Of Kansas City in Kansas and its agents from any and
all responsibility or liability. I understand that I will receive no compensation, should any photograph of me or my child be
used.

#4 Parent or Guardian Signature __________________________________________________ Date _____________

TRANSPORTATION HOME
At the conclusion of camp, your child will be leaving with his/her parents. Yes _____ No _____
I am not able to pick up my child from camp; he/she has my permission to ride home with ___________________________
Camper will not be allowed to leave with anyone who is not named on this form.

COMPLETING REGISTRATION—Registration is NOT complete without the following items:

1. Make sure all blanks on the form are complete and all four signature blanks are signed.
2. Enclose a photo copy of health insurance card.
Page 3 of 3 Youth Residential Camp

3. Send a wallet-size photo of camper (will not be returned).

4. En
5.
6. Enclose a $100 non-refundable deposit check made payable to Camp Tekakwitha.
5. Earliest ACCEPTED postmark date: February 1, 2010, for 7th thru 12 grade campers
and February 8, 2010, for 5th & 6th grade campers.
Earlier postmarks will be returned!
 FAMILY CAMP TEKAKWITHA 2010
Prairie Star Ranch
Please mail to: Camp Tekakwitha
Archdiocese of KC in KS
12615 Parallel Parkway
Kansas City, KS 66109
REGISTRATION & HEALTH FORM
FOR July 16-18 FAMILY CAMP ONLY
Age # of campers Cost Total
Age 0-2 (no babysitting) __________ FREE ________
Family Camp Page 1 of 3
Ages 2 years old and up __________ $125 ________
TOTALS __________ ________
Please print and use blue or black ink only.
Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___
Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___
Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___
Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___
Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___
Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___
Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___
Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___
Camper’s Name ____________________________________ Age (at camp time) _____ DOB: __/___/___
Home Phone # (_____)________________ Additional Phone # (_____)________________
Street Address ________________________________E-mail Address _________________________
City ___________________________________________ State ____________ Zip ______________
Parish _________________________________________ Parish City__________________________
Mother’s Name ________________________ Phone (Day) (____)________ (Evening) (____)_________
Mother’s Complete Address (if different than above) ____________________________________________
Father’s Name _________________________ Phone (Day) (____)________ (Evening) (____)_________
Father’s Complete Address (if different than above) _____________________________________________
Additional Emergency contact in case you cannot be reached (not at camp):
_______________________________________________________________________________________________
Phone # (____)_____________________ Relation to parents _________________________________
 FAMILY CAMP TEKAKWITHA 2010
Prairie Star Ranch
Page 2of 3 of Family Camp Registration
Please note there are 3 areas requiring signatures!!!
Doctor’s Name and Clinic:______________________________________________________________________
Doctor’s Full Address: _________________________________________________________________________
Doctor’s Phone #: (_____)____________________
Family Camp Page 2 of 3
Are all immunizations up to date? Yes _____ No _____
Dates of last tetanus booster for each family member: ________________________________________________
________________________________________________________________________________________
If any are not up to date please list them. __________________________________________________________
Please list any special dietary needs for your family. _________________________________________________
________________________________________________________________________________________
Notify the staff if any family member is exposed to a communicable disease during the three weeks prior to camp.
Allergies/Conditions (List which family member is allergic to or has any of the following conditions):
Bee Stings ______ Poison Ivy ______ Asthma ______ Fainting ______
Penicillin ______ Sulfa ______ Seizures ______ Hay Fever ______
Other _______________________________________________________________________________________
If any of the above were checked yes, please submit a statement in space provided below of how the family member
has been treated and with what medications. Please also list (use back of page 3 if necessary):
1. Any operations or serious injury in the past two years.
2. Medical limitations or needs that we need to be aware of.
3. Any limitations or needs (learning styles, family situations, custody arrangements, etc.)
Are all of youth family member that are coming to camp in general good health and able to participate in normal
camp activities? Yes _____ No _____
!!!! VERY IMPORTANT !!!!
You MUST have written verification FROM LICENSED MEDICAL PERSONNEL that the camper has had a
health examination during the past 24 months and a record SHOULD INCLUDE: any physical condition requiring
restrictions on participation in camp and descriptions thereof, date of exam, and current on-going treatments or
medications, and record should be signed and dated. If you already have a sports physical form from the past 24
months, it will also be sufficient for verification of campers’ health, or use our Health Exam Waiver (one page
Archkck Form) included in this packet. THIS INFORMATION MUST BE BROUGHT WITH YOU THE FIRST
DAY OF CAMP. PLEASE DO NOT MAIL. (This Information Required by ACA).
Date of most recent physical examination by a licensed medical doctor. Date: ____/____/____
Date of most recent physical examination by a licensed medical doctor. Date: ____/____/____
Date of most recent physical examination by a licensed medical doctor. Date: ____/____/____
Date of most recent physical examination by a licensed medical doctor. Date: ____/____/____
Date of most recent physical examination by a licensed medical doctor. Date: ____/____/____
(If upcoming appointment set, please note:__________________________________________________.)
In case of medical emergency, I understand that every effort will be made to contact parents or guardian of camper.
In the event that I cannot be reached, I hereby request and give permission to the physician selected by the Camp to
hospitalize, secure proper treatment for and to order anesthesia or surgery for my child, as named herein. In signing
this health form, I hereby certify that the information is correct and give permission for the release of medical
records to an attending physician in case of illness or emergency. I request that my child be transported to seek
needed medical attention.
#1 Signature of Parent/Guardian___________________________________________ Date _____________
 FAMILY CAMP TEKAKWITHA 2010
Prairie Star Ranch
Page 3 of 3 of Family Camp Registration
#1 Signature of Parent/Guardian___________________________________________ Date _____________
#1 Signature of Adult Family Member_______________________________________ Date _____________
#1 Signature of Adult Family Member_______________________________________ Date _____________
Health Insurance Company ______________________________________________________________________
Family Camp Page 3 of 3
Health Insurance Policy # _______________________________________________________________________
Primary Health Insurance holder and name and Social Security # ________________________________________
A Photocopy of the Primary Health Insurance card MUST be submitted with this form.
I request that my family ____________________ be allowed to participate in the camp activities at Family Camp
Tekakwitha at the Archdiocesan Camp in Williamsburg, KS. I hereby release and indemnify the Archdiocese of
Kansas City in Kansas, its staff, and volunteers from any liability arising from claims of any kind of nature
whatsoever from my child’s participation in this program. The activities may include horseback riding, high ropes
challenge, power kiting, stunt kiting, canoeing, hiking, orienteering, rock climbing, rappelling, basketball, soccer,
swimming, technical tree climbing, group party games, archery, volleyball, mountain biking, mountain boarding,
outdoor camping, softball, numerous Catholic prayer experiences, and other outdoor camp activities.
#2 Signature of Parent/Guardian___________________________________________ Date _____________
#2 Signature of Parent/Guardian___________________________________________ Date _____________
#2 Signature of Adult Family Member_______________________________________ Date _____________
#2 Signature of Adult Family Member_______________________________________ Date _____________
PHOTO RELEASE
I hereby authorize the Archdiocese Of Kansas City, and its agents to utilize my child’s photographic image for the
specific purpose of publication of the Archdiocese Of Kansas City events (including promotional materials). In
giving my consent, I hereby release and hold harmless the Archdiocese Of Kansas City and its agents from any and
all responsibility or liability. I understand that I will receive no compensation, should any photograph of me be used.
#3 Signature of Parent/Guardian___________________________________________ Date _____________
#3 Signature of Parent/Guardian___________________________________________ Date _____________
#3 Signature of Adult Family Member_______________________________________ Date _____________
#3 Signature of Adult Family Member_______________________________________ Date _____________
Please mail to:
Camp Tekakwitha
Archdiocese of KC in KS
12615 Parallel Parkway
Kansas City, KS 66109
Registrations MUST BE
postmarked; hand delivered
registrations will NOT be accepted.