Adult Registration Form

Medical Registration Form
Emergency Contact Information
Emergency Contact's Name *

First Name Last Name
Relationship *
Primary Phone Number *
Alt. Phone Number (if applicable)
-OR CALL-
Emergency Contact's Name *

First Name Last Name
Relationship *
Primary Phone Number *
Alt. Phone Number (if applicable)
MEDICAL INFORMATION
Does the adult have any known allergies? If so, please describe below: *
If no known allergies, please put N/A for Not Applicable
Does the adult have any activity restrictions? If so, please describe below: *
If no known restrictions, please put N/A for Not Applicable
Does the adult have a chronic physical condition? If so, please describe below: *
If not, please put N/A for Not Applicable
Does the adult required any special dietary needs (such as gluten-free, diabetic dietary needs, etc.)? If so, please describe below: *
If not, please put N/A for Not Applicable
Does the adult have any required present medication? If so, please describe below and the dosage required: *
If not, please put N/A for Not Applicable
If the adult has been tested or treated for any serious physical or psychological illness within the past 3 years, please list below:
In case of needed medical attention, permission is given to the Barbourville Penetcostal Youth Camp and its designee to seek appropriate medical care for the above-referenced participant.

For this purpose, the following information is given below:
Family Physician *
Phone Number *
Please enter a valid phone number.
Insurance Company *
A copy of the card is required below
Group # *
Individual # *
I, parent/guardian name* ,hereby state that the above-named BPYC participant, is in good physical condition and has no contagious or infectious disease or symptons of the same as of this date.
Parent/Guardian Signature *

Clear
Date *

Month Day Year
Today's Date
Confirmation BY ACKNOWLEDGING AND SIGNING ABOVE, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
A copy of the insurance card for the adult is required to keep on file in case of medical emergency.

Please upload a copy of the front and back of insurance card below.

Note: if you are taking a picture of the insurance card, please make sure the picture is clear and the information on the card is easily visable.
File Upload *

Cancel of
Total price per volunteer is $40.00

Counselors/Directors have no charge.

(The deposit should be paid by the church)
Should be Empty:

Adult Registration Form

Medical Registration Form