Children's Camp Medical Permission and Release Form

Associational Children's Camp Medical, Permisson, Release, and Payment Form

Please complete this form by June 1st. The camp dates are 6/17/24 - 6/20/24. Please visit the GCA website for more information about children's camp: www.gcasbc.org/childrens-camp-2024
Church Name*
Individual's Information
Name*

First NameLast Name
Birthdate*

MonthDayYear
(month, day, year)
Shirt Size*

XS KidsS KidsM KidsL KidsS AdultM AdultL AdultXL AdultXXL AdultXXXL Adult
Home Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*

First NameLast Name
Parent Cell Phone Number*

Area CodePhone Number
Parent Email*
example@example.com
Emergency Contacts
Emergency Contact #1 Name*

First NameLast Name
Emergency Contact #1 Phone Number*

Area CodePhone Number
Emergency Contact #2 Name*

First NameLast Name
Emergency Contact #2 Phone Number*

Area CodePhone Number
Medical Information
Physician Name*

First NameLast Name
Physician Phone Number*

Area CodePhone Number
Insurance Co.*
Policy #*
Updated Tetanus Shot*

YesNo
Tetanus Shot Date*
Medical History

AsthmaHeadachesStomach IssuesOther
Previous Surgeries*
Current Medications*
My child may be given any of the following (Please choose yes or no)*

Tylenol: YesTylenol: NoIbuprofen: YesIbuprofen: NoPepto-Bismol: YesPepto-Bismol: NoBenadryl: YesBenadryl: NoOther
Food Allergies
Medication Allergies
Insect Stings/Poison Oak Allergies
Special Diet
Permission to Photograph

I give permission for my child to be photographed while at Children’s Camp. A group photo will also be given to each participant at camp. (If you would prefer for your child not to be included in social media posts, please indicate any of these special requests on the comment/question section below.)
Permission for Treatment

My permission is granted for the Camp Director or staff person in charge to obtain necessary medical attention in case of sickness or injury of my child.
Liability Release

I, the undersigned, verify that the information on this registration form is correct and release and forever discharge all sponsors and the Great Commission Association of Sothern Baptist Churches from any and all claims, demands, actions or cause of action past, present, or future arising out of any damage or injury while participating in camp.
Signature*

Clear
Anything else we need to know about your child
Comments/Questions:
How are you paying? (Registration is not complete until payment is received.)*

By PayPal/Debit/Credit cardBy Check (send to the GCA office)By My Church (group payment)
Group Payment: If you are paying for a group, please list the camp or counselor participants' first and last names here. (Please indicate if the participant is a camper or a counselor.)
Group Payment Note: Each camp participant will need to fill out this registration form individually and indicate that your church will make a group payment. Your church may send a check to the GCA office or pay via this form below.
Children's Camp Payment: (Payment can be made via PayPal/Debit/Credit card below.)
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Kid Camper for June 202 Children's Camp $200.00

Quantity
Item subtotal:$0.00

Counselor for June 2024 Children's Camp$200.00

Quantity
Item subtotal:$0.00

Total $0.00

Payment Methods

Debit or Credit Card

First Name

Last Name

Credit Card Number

Card Expiration

Security Code

Please click one of the PayPal options to complete payment and submit the form.

Should be Empty:

Associational Children's Camp Medical, Permisson, Release, and Payment Form