Camp Northlake Counselor Registration

Medical Form
Camper's Date of Birth*

MonthDayYear
Date
Does the counselor have any special medical problems, allergies, etc.?*

NoYes, Please Describe
Are medications being taken?*

NoYes, Please Describe
To our knowledge the counselor is physically able to participate in all activities.*

YesNo, Please Describe
Name of counselor Physician:
Phone Number of Counselor's Physician
Please enter a valid phone number.
Insurance Information- Please type information below (or send a picture of your insurance card to Abbey (abbey@northlake.org or 404-409-9624))

CAMP NORTHLAKE PARENT PERMISSION FORM
I hereby give permission for my child(ren) to participate in Camp Northlake. I hereby release Crystal O’Neal, Northlake Church of Christ, their staff and any other person acting on behalf of Crystal O’Neal in connection with participation in the camps; from any responsibility and liability for any injury or illness that my child may sustain during this activity.

In the event of an emergency, I hereby authorize an adult leader of this activity, as an agent for me, to consent to any x-ray examination; medical, dental, or surgical diagnosis; treatment; and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the State where the services are rendered, either at a doctor’s office or at any hospital. I expect to be contacted as soon as possible.
Signature of natural parent or legal guardian (if counselor is under 18)*

Clear
Date *

MonthDayYear
Date
Should be Empty:

Parent/Guardian Information