Camper Information
$175 (per camper)
Please fill out form for each camper/volunteer separately. Thank you **Before beginning** Please have images/pdf of front and back of camper/volunteer insurance card available to attach/upload.
Submission Date
-
Month
-
Day
Year
Date
Camper Name
*
First Name
Last Name
Nickname
*
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School (NA if not applicable)
*
List NA if not applicable
Grade
*
Please Select
NA
2
3
4
5
6
7
8
9
10
11
12
Shirt Size
*
Please Select
3T
4T
YS
YM
AS
AM
AL
AXL
A2XL
A3XL
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Parent / Guardian Information
Parent Name
*
First Name
Last Name
Parent Email
*
example@example.com
Please list all phone number where parent/guardian can be reached
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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Emergency Contact Information
Emergency Contact 1
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
*
Emergency Contact 2
*
First Name
Last Name
Relationship
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Medical / Insurance Information
Primary Care Physician Name
*
Physician Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Please upload image/pdf of camper insurance card
*
Browse Files
Drag and drop files here
Choose a file
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of
Date of Last Tetanus Shot
*
-
Month
-
Day
Year
Date
Insurance Company
*
Policy / Group ID#
*
Policy Holders Name
*
First Name
Last Name
Insurance Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Camper / Participant Past Medical History
*
N/A
Diabetes
High Blood Pressure
Hypothyroidism
Goiter
Cancer
Leukemia
Psoriasis
Angina
Heart Problems
Heart Murmur
Pneumonia
Pulmonary Embolism
Asthma
Emphysema
Stroke
Epilepsy (seizures)
Cataracts
Kidney Disease
Kidney Stones
Chrons Disease
Colitis
Anemia
Hepatitis
Stomach or Peptic Ulcer
Rheumatic Fever
Tuberculosis
HIV / AIDS
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Medications
List all medications the participant will take during any THRIVE trips, retreats, or events. This includes any prescription, non-prescription medications, herbal supplements, and vitamins. any participant under theage of 18 is required to give ALL MEDICATIONS to the adult youth leader in their original containers with complete dispensing instructions before the start of the event. Youth are not permitted ot carry any prescription or non-prescription medication and will be sent home at the parent/guardian's expense if they do.
Medication Name, Dose, Treatment for, Dispensing Instructions (NA if not applicable)
*
Example: Zyrtec, 5mg, Seasonal allergies, Take one pill daily in the morning with food
List any medical conditions about the participant (asthma, diabetes, epilepsy, etc. )(NA if not applicable):
*
List any allergies of the participant (dug/medicine, food, and/or environmental) and the severity and type of reaction (NA if not applicable):
*
Please explain any other pertinent information about the participant (i.e. physical, behavioral, or emotional) that would be important for the adult leaders to know.(NA if not applicable)
*
Over - the - Counter Medication Permission: Do you give permission for the participant to be give over-the-counter medication as needed and as directed on teh label, to treat non-emergency medical conditions that do not require a doctor or hospital visit such as a minor headache, stomach ache, or allergic reaction (i.e. Tylenol, Advil, antacids, Benadryl) while at a youth ministry THRIVE event?
*
No. Contact me or get medical help if my child has any minor medical concerns.
Yes. I give permission for an adult youth leader to give my child approved over-the-counter medications as directed on an as needed basis to treat non-emergency medical conditions.
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Liability / Parental Consent
Name of Camper
First Name
Last Name
Name of Parent/Guardian
First Name
Last Name
Camper/ Participant Signature
*
Parent/Guardian Signature
*
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Should be Empty: