First Name		Last Name
Address

City

State

Zip

Age

Work Phone

Home Phone

Mobile Phone

Parents Name

Church/Pastor's Name

Your Email

T-Shirt Size

Child Small Child Medium Child Large Child XLarge Adult Small Adult Medium Adult Large Adult XLarge

 

•••••••••••••• MEDICAL INFORMATION AND AUTHORIZATION ••••••••••••
• ALL medication MUST be in the child’s name.
• PLEASE DO NOT bring over the counter medications (Advil, Tylenol, Aspirin, etc. – We will supply if needed!)

 

Special Medication (be specific):

(Bring only a registered camper’s medication in camper’s own labeled bottle with Dr.’s and pharmacy’s name clearly typed)

Lactose Intolerant:

Yes  No

Allergic Reactions: Bee Stings

Yes  No

Allergic Reactions: Penicillin

Yes  No

Allergic Reactions: Other:

Yes No

Type of Reaction:

Treatment Given:

Physical Handicaps, disorders, or Diseases (include infectious) :

Restricted Activities (include reason):

Date of last Tetanus shot:

/

/

(Tetanus shots should be up-to-date). DTAP has to be less than 10 yr. old.

Insurance Company:

Policy No.:

Insurance Address:

Ins. Phone:

Medical Authorization: In case of Medical emergency, I hereby give my permission to the staff member in charge to: Hospitalize, and/or secure the services of a licensed physician, surgeon, or anesthetist in providing the necessary care for my child as named on this application. I certify that my child is in good physical condition, and is able to participate in the entire camping program except for activities listed as “restricted”.

Signature of Parent or Legal Guardian: Please type your name, read the statement below and check the box after the statement.  

“I have personally filled out this information and deemed it correct to the best of my ability. By checking this box I agree that I have signed this form.

Date: