"*" indicates required fields Choose your weekCamp*Select BelowCamp Good NewsBlueberry MountainCEF® of Southern MaineCEF® of Eastern MaineCEF® of Central MaineCEF® of Western MaineCEF® of Northern MaineThe Neighborhood HouseWeek*Select BelowWeek 1: (ages 8-13) Jun 30 - Jul 5Week 2: (ages 8-13) Jul 7 - Jul 12Week 3: (ages 8-13) Jul 14 - Jul 19Week 4: (ages 14-17) Jul 21 - Jul 26Week 5: (ages 8-13) Jul 28 - Aug 2Week 6: (ages 8-13) Aug 4 - Aug 9Week 7: (ages 8-13) Aug 11 - Aug 16Week*Select BelowWeek 1: (ages 8-13) Jun 30 - Jul 5Week 2: (ages 8-13) Jul 7 - Jul 12Week 3: (ages 8-13) Jul 14 - Jul 19Week 4: (ages 14-17) Jul 21 - Jul 26Week 5: (ages 8-13) Jul 28 - Aug 2Week 6: (ages 8-13) Aug 4 - Aug 9Week 7: (ages 8-13) Aug 11 - Aug 16Week*Select BelowWeek 1: (ages 8-13) Jun 30 - Jul 5Week 2: (ages 8-13) Jul 7 - Jul 12Week 3: (ages 8-13) Jul 14 - Jul 19Week 4: (ages 14-17) Jul 21 - Jul 26Week 5: (ages 8-13) Jul 28 - Aug 2Week 6: (ages 8-13) Aug 4 - Aug 9Week 7: (ages 8-13) Aug 11 - Aug 16Week*Select BelowWeek 1: (ages 8-13) Jun 30 - Jul 5Week 2: (ages 8-13) Jul 7 - Jul 12Week 3: (ages 8-13) Jul 14 - Jul 19Week 4: (ages 14-17) Jul 21 - Jul 26Week 5: (ages 8-13) Jul 28 - Aug 2Week 6: (ages 8-13) Aug 4 - Aug 9Week 7: (ages 8-13) Aug 11 - Aug 16Week*Select BelowWeek 1: (ages 8-13) Jun 30 - Jul 5Week 2: (ages 8-13) Jul 7 - Jul 12Week 3: (ages 8-13) Jul 14 - Jul 19Week 4: (ages 14-17) Jul 21 - Jul 26Week 5: (ages 8-13) Jul 28 - Aug 2Week 6: (ages 8-13) Aug 4 - Aug 9Week 7: (ages 8-13) Aug 11 - Aug 16Week*Select BelowWeek 1: (ages 8-13) Jun 30 - Jul 5Week 2: (ages 8-13) Jul 7 - Jul 12Week 3: (ages 8-13) Jul 14 - Jul 19Week 4: (ages 14-17) Jul 21 - Jul 26Week 5: (ages 8-13) Jul 28 - Aug 2Week 6: (ages 8-13) Aug 4 - Aug 9Week 7: (ages 8-13) Aug 11 - Aug 16Week*Select BelowWeek 1: (ages 8-13) Jun 30 - Jul 5Week 2: (ages 8-13) Jul 7 - Jul 12Week 3: (ages 8-13) Jul 14 - Jul 19Week 4: (ages 14-17) Jul 21 - Jul 26Week 5: (ages 8-13) Jul 28 - Aug 2Week 6: (ages 8-13) Aug 4 - Aug 9Week 7: (ages 8-13) Aug 11 - Aug 16Week*Select BelowWeek 1: (ages 8-13) Jun 30 - Jul 5Week 2: (ages 8-13) Jul 7 - Jul 12Week 3: (ages 8-13) Jul 14 - Jul 19Week 4: (ages 14-17) Jul 21 - Jul 26Week 5: (ages 8-13) Jul 28 - Aug 2Week 6: (ages 8-13) Aug 4 - Aug 9Week 7: (ages 8-13) Aug 11 - Aug 16Who's paying for camp?*Select BelowGuardianChurch / 3rd PartyCamp ScholarshipYour Email Address* General InformationName* First Last Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Bunk With: Birth Sex*Select BelowMaleFemaleBirth Date* MM slash DD slash YYYY Age During Camp*Please enter a number from 8 to 17.Completed Grade* First Adult Contact Name* Phone*Relation*Select BelowMotherFatherGuardianSecond Adult Contact Name* Phone*Relation*Select BelowMotherFatherGuardianEmergency ContactIf a parent is not available, please notifyName* Relation* Phone*Health and InsuranceInsurance InformationInsurer* Subscribers Name* Policy Number(s)* Are you now, or have you ever been treated for any of the followingPlease mark no, yes, or serious for each one.Asthma and breathing difficulties* No Yes Serious Allergies (Insect stings)* No Yes Serious Autism Spectrum* No Yes Serious Bed-Wetting* No Yes Serious Diabetes Ear/sinus problems GI problems (abdominal, digestive)* No Yes Serious Emotional difficulties* No Yes Serious Fainting spells* No Yes Serious Heart disease (CHF, CAD, MI)* No Yes Serious Hypertension (high blood pressure)* No Yes Serious Kidney disease Sleep disorders (sleep apnea)* No Yes Serious Learning disorders (ADHD, ADD)* No Yes Serious Psychiatric or Psychological Issues* No Yes Serious Seizures* No Yes Serious Serious Injury* No Yes Serious Surgery* No Yes Serious Thyroid disease* No Yes Serious Other Medical Conditions Please share any info the nurse should knowPlease list any food, medical, or environmental ALLERGIES and type of reactionPlease list any names of medication (including vitamins) needed to be taken while at campAll medicine and vitamins MUST be in their original containers.Please list any self-administered medications the camper is bringing (Inhalers, Epi Pens, Other)To carry this item, you must send a signed doctor's note that student is capable of self-administering it. Email: cgnregistrar@cefofmaine.org IMMUNIZATION HISTORYPlease give exact dates OR send a copy of immunization record to: Email: cgnregistrar@cefofmaine.orgDiptheria, Tetanus, Pertussis(DTaP, DT, DTaP-Hib, Dtap - HepB-IPV, Td) MM slash DD slash YYYY Hepatitis A(HepA) MM slash DD slash YYYY Haemophilus influenzae type b(Hib, HepB-Hib, DTaP Hib) MM slash DD slash YYYY Hepatitis B(HepB, HepB Hib, DTaP HepB-IPV) MM slash DD slash YYYY Influenza Inactivated(Intramuscular or LAIV) MM slash DD slash YYYY Measles, Mumps, Rubella(Date of Vaccination) MM slash DD slash YYYY Meningococcal(Date of Vaccination) MM slash DD slash YYYY Polio(IPV, DTaP-HepB IPV) MM slash DD slash YYYY Pneumococcal Conjugate(PCV7) MM slash DD slash YYYY Varicella(var) MM slash DD slash YYYY Other Date of the camper's last tetnus shot MM slash DD slash YYYY If you do not choose to vaccinate, please indicate why hereSelect BelowReligiousMedicalPhilisophicalCONSENT FOR MEDICAL TREATMENT By signing below you are affirming the following statement: To the best of my knowledge, this health history is correct, and the person herein described has permission to engage in all camp activities. I hereby give permission for the camp nurse to administer prescribed medications, including non-prescription medications for mild illness, and to assess and administer treatment for my child as named above. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, and to order injections, anesthesia or surgery for my child as named above.Signature* Note: On electronic forms your typed signature carries the same weight as your written signatureCONSENT FOR MEDIA USE Child Evangelism Fellowship® may, from time to time, document the activities of the ministry with photos or videos. By selecting "Yes" below, you are affirming the following statement: "I hereby assign and grant to Child Evangelism Fellowship Inc., its subsidiaries and successors, and assign the unqualified right to the ownership or use of all photographs or video of me or my minor child, without reservation or limitation, including use of photographs or video of me or my minor child for, but not limited to, advertising, educational and promotional purposes.I affirm the above statement* Yes No Any additional info we should be aware of?Are you interested in other CEF of Maine ministeries in your local area throughout the year? Yes No NameThis field is for validation purposes and should be left unchanged.