Registration

CONFIDENTIAL MEDICAL HISTORY AND MEDICAL AUTHORIZATION

Participant and guardian must read and sign this entire form. This completed and signed form must be on file for the camper to participate in activities with Discovery Ministries, 17043 State Route E, Eminence, MO 65466, 573-226-3213
Participant Basic Information
Group/Trip Name
Retreat/Trip Date

MonthDayYear
Date
First Name*
Last Name*
Salutation
Street Address*
City*
State*
Zip Code*
Phone*
Please enter a valid phone number.
Email*
example@example.com
Birthdate*

MonthDayYear
Date
Sex*
Today's Date

MonthDayYear
Age*
Weight in lbs.*
e.g. 6
Height: Feet Feet*
Inches Inches*
Emergency Contact
Emergency Contact*

First NameLast Name
Relationship with Emergency Contact*
Their relationship to you (e.g. "Mother")
Emergency Contact Address*

Street Address

Street Address Line 2

CityState (2 letter postal abbreviation please)

Zip Code
Emergency Contact Primary Phone Number*
Please enter a valid phone number.
Emergency Contact Secondary Phone Number
Please enter a valid phone number.
Physician Information
Physician's Name*

First NameLast Name
Physician's Phone Number*
Please enter a valid phone number.
Physician's Address

Street Address

Street Address Line 2

CityState

Zip Code

CONFIDENTIAL MEDICAL HISTORY AND MEDICAL AUTHORIZATION