Junior Camp 2025 Registration Form

Junior Camp June 7, 2025
Junior Camp Registration

All Submissions Due by June 6, 2025
Camper Information:
Camper's Name:*

First NameLast Name
Camper's Preferred Name:
(Any name other than their legal name)
MaleFemale
Camper's Age:*
4-13 Years
Grade Camper is Going Into:*
Kindergarten - 6th Grade:
Camper's Birth Date:*

MonthDayYear
Transportation to Pool:*
Camper Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information:
Parent/Guardian Full Name:*

First NameLast Name
Parent/Guardian Relationship:*
(Mother, Father, Grandparent, or Guardian)
Parent/Guardian E-mail:*
example@example.com
Parent/Guardian Primary Number:*

Area CodePhone Number
YesNo
HomeWorkN/A
Parent/Guardian Alt. Number:*

Area CodePhone Number
YesNo
Parent/Guardian Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Medical Information:
YesNo
If Yes, Please List Allergy, Severity, Reaction, and Treatment*
YesNo
YesNo
Inhaler Instructions.*
YesNo
If Yes, Please Describe:*
YesNo
DiabetesHeart ConditionsLung ConditionsMusculoskeletal ConditionsOther Condition Not Listed
Please Describe Any Impact or Treatments Needed:*
YesNo
If Yes, Please List for Administration by Camp Nurse:*
Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in any and all activities prepared by Elmwood Baptist Church's JR Camp leaders.
Medical Release and Authorization As Parent and/or Guardian of the named camper, I hereby authorize Jr. Camp Nurse to provide first aid and basic medical services as described above. This release is authorized and executed with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of the named minor child, in my absence.
Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

(Write with finger or stylus your signature above)
Printed Name*
Name of Authorized Signature Above
Should be Empty:

Junior Camp June 7, 2025

Junior Camp Registration

Camper Information:

Parent/Guardian Information:

Medical Information: