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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 camper should not be released to? *

If yes, please specify name(s).

Please check if you have had the following conditions:

Measles
Polio
Chicken Pox
Scarlet Fever
Whooping Cough

Chronic/Recurring Conditions: Please check all that apply. *

Asthma/Respiratory Problems
Bleeding/Clotting Disorder
Hearing Impairment
Ear Infection
Emotional Disturbances
Epilepsy
Fainting
Headaches
Diabetes
Heart Disease
Hypertension
Kidney Disease
Musculoskeletal Disorder
Nosebleeds
Seizures
Sickle Cell Trait/Disease
None

Other Conditions: Please Specify

Date of Last Exam? *

Are any Activities Restricted? *

If yes, please explain.

Allergies: Please check all that apply. *

Animals
Food
Insects
Medicines
Plants
Pollen
Hayfever
Other
None

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!