Summer Camp

Emergency Contact 1
Name

First NameLast Name
Phone Number

Area CodePhone Number
Emergency Contact 2
Name

First NameLast Name
Phone Number

Area CodePhone Number
Physician and Medical Information
Name

First NameLast Name
Phone Number

Area CodePhone Number
Preferred Hospital
Insurance/Health Coverage (Company)
Please note that The Tabernacle Ministries insurance will not be liable for offsite and outside insurance coverage for students. All students will and shall be covered by personal insurance of parents or guardians. The Tabernacle Ministries insurance will cover in the facility occurrences only due to insurance rules and regulations. Please sign below that you acknowledge this statement.
Signature

Clear
Please list any of the following: Current medications, Medication allergies, Food allergies, Chronic health concerns.
Medication will not be administered to students. Please sign below of your acknowledgement of this statement.
Signature

Clear

Previous School 1
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Previous School 2
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Previous School 3
School Name
City
State
Date Started

MonthDayYear
Date Ended

MonthDayYear
Notes
Please inform the office of any other vital information you think they may need to know in the event of an emergency. Thank you.
Tabernacle Ministries Academy has permission to photograph my child for the purpose of advertising on the website and news publications.*
Please type (1) Yes or (2) No.
Take Photo
Tabernacle Ministries Academy has permission to take my child on field trips. *

Father's place of employment
cellphone   Area Code   Phone Number   work phone   Area Code   Phone Number   home phone   Area Code   Phone Number

Mother's place of employment   Type a label
cellphone  Area Code   Phone Number   work phone   Area Code   Phone Number   home phone   Area Code   Phone Number
Should be Empty:

School Registration