Registration

First and Last Name *

Name Camper Goes By

Street Address or P.O. Box *

City *

State *

Zip *

Camper Cell Phone *

Email *

Gender *

Male
Female

Grade Next Fall

Birthdate *

Age *

T-Shirt Size - Please choose one:

Church Name & City, State *

Youth Pastor and/or Pastor Name *

Parent/Guardian Name *

Parent/Guardian Cell Phone *

Parent Email *

If Parent cannot be notifified in case of an Emergency, please notify: *

Emergency Phone *

Is there anyone your should should not be released to? *

If yes, please specify name(s).

Immunizations: Texas State regulations require us to obtain immunization dates for each camper in case a medical emergency should arise. "Current", "on record at school," and "up to date" cannot be accepted as an immunization date. Please be sure to list at least the month and year of immunization. Please indicate "we have chosen not to immunize" if your student has not received immunizations in the box below.

Oral Polio *

Rubella *

DPT *

Measles *

Mumps *

TB Test *

Other Conditions: Please Specify

Date of Last Exam? *

Are any Activities Restricted? *

If yes, please explain.

Please list specifics of any allergy checked or list additional allergies. *

Please list any current medications. *

Will the above medications be needed at camp? *

May the camper be given Tylenol? *

May the camper be given Benadryl? *

May the camper be given Ibuprofen? *

May the camper be given over the counter, non-prescription medications or applications, not to exceed the recommended dosage for stomach discomfort, burns, cuts, insect bites, rash or scrapes? *

Check if you wear:

Glasses
Contact Lenses
Dental Appliances
Other

Can you swim? *

Physician Name & Phone Number *

Health Insurance *

Group/Policy Number *

Please leave any comments about your camper that will help us serve him/her better.

Parent Signature: (Electronic signature will signify your agreement to the Authorization & Medical Release written below.) *

Camper Signature: (Electronic signature will signify your agreeemnt to the Authorization & Medical Release written below.) *

Alert!