Bosco Ministries Boys Programs General Application
Application for all programs that are for boys younger than 18. Please be sure to select the proper program.
Camp Program
Camp St. Isaac Jogues
Camp St. Peter - Session 1
Camp St. Peter - Session 2
Sursum Corda (High School Program)
Applicant First Name
Applicant Last Name
Applicant Age
Birthdate
Weight
Height
Address Line 1
Address Line 2
City
State
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Zipcode/Postal Code
Parent First Name
Parent Last Name
Phone
Email
Relationship to Applicant
Father
Mother
Grandfather
Grandmother
Uncle
Aunt
Cousin
Friend
Applicant Lives With
Both Parents
Father
Mother
Guardian
Emergency Contact First Name
Emergency Contact Last Name
Emergency Contact Phone. Preferably mobile.
Emergency Contact Relationship to Applicant
Friend
Uncle
Aunt
Cousin
Grandmother
Grandfather
Pertinent Non-Medical Information
Do any members of the applicant’s family have a history of heart disease, diabetes, seizures, mental or emotional illnesses?
Does the applicant have any present physical illness or disability?
Does the applicant have a history of or currently have any emotional or mental illnesses including but not limited to: depression, anxiety, autism, Down Syndrome?
Does the applicant have a history of behavioral problems, drug or alcohol use?
Will the applicant be taking any medications during the time of the program?
Does the applicant have a history of sleep disorders (e.g. sleepwalking, wetting the bed, insomnia, nightmares, etc.)?
Has the applicant ever been hospitalized or had surgery?
Allergies?
Asthma?
Common childhood diseases?
Seizures?
Frequent colds or sore throats?
Depression?
Frequent earaches?
Frequent or severe headaches?
Heart murmur or heart abnormality?
High blood pressure?
Has the applicant ever had severe reactions to an insect bite?
“Passed out” or “knocked out”?
Shortness of breath?
Concussion?
Skin problems?
Please explain all 'Yes' answers to the above list. If the applicant requires any particular consideration, care, medication, (e.g. epipen, protective head gear for sports, etc.) please explain here.
Please note any other pertinent medical history details:
Hearing Aid?
Glasses?
A special diet? (e.g. Allergies)
Any other special requirements we should be aware of?
If any special requirements, please list them here.
Covered by insurance?
Insurance Coverage First name
Insurance Coverage Last name
Insurance Company Name
Insurance Address 1
Insurance Address 2
Insurance Address City
Insurance State (2 Letter Abbrev.)
AK
AL
AR
AZ
CA
CO
CT
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Insurance Zip
Insurance Policy Number
By completing this application, I acknowledge and agree to all of the terms, release, and consent detailed on the organization website, and required by Bosco Ministries (St. John Bosco Camps), as the applicant's parent or legal guardian.