Church in Atlanta Bible Camp Registration

Emergency contact, medical release, and insurance information
I authorize The Church in Atlanta Bible Camp serving ones to obtain and direct any and all medical and/or emergency care which in the bearer’s opinion is needed by my child(ren). By signature hereto I hereby release and hold harmless the Church in Atlanta, Inc., of any and all liability with respect to any medical care, medical decisions, treatment, or matters that may arise. I also accept full responsibility for the payment of any expenses incurred from such medical and/or emergency care.
Parent/Guardian signature

Clear
Signature date*

MonthDayYear
Date
Emergency contact name (someone other than yourself)*
Emergency contact phone number*
Emergency contact's relationship with child*
Family physician*
Physician's phone number*
Are your children all on the same insurance plan as you?*
Family insurance provider*
Family insurance policy or group number*
Child 1 Insurance company*
Child 1 Policy number*
Child 2 Insurance company*
Child 2 Policy number*
Child 3 Insurance company*
Child 3 Policy number*

Authorized pick-up persons

Please indicate below the persons (other than yourself) who are authorized to pick-up your child(ren). If you don't wish to designate anyone else to pick-up your child, leave field blank and go to next page.
Should be Empty:

General Family Registration