BCBA LEADER REGISTRATION FOR CAMP:
Name of Camp Attending
Please Select
Camp Merge - FBC Amarillo
Start Date of Camp
Please Select
July 13
Leader Name
*
Gender
*
Please Select
Female
Male
Age
*
Birth Date
*
/
Month
/
Day
Year
Date
Primary Phone
*
Format: (000) 000-0000.
Mobile Phone. If this is the same as your primary number, please re-enter.
*
Format: (000) 000-0000.
Address
*
Address
Street Address Line 2
City
State
Zip
T-Shirt Size
*
Please Select
YS
YM
YL
AS
AM
AL
AXL
A2XL
A3XL
Name of Church or Organization leader will be with
*
Please Select
First Baptist Church Amarillo
Leader's Sponsor or Counselors Name
*
Please Select
Hannah Bandy
Sponsor or Counselors Phone Number
*
Please Select
806-373-2891
Emergency Contact
*
Relationship to Leader
*
Primary Phone
*
Format: (000) 000-0000.
Mobile Phone. If this is the same as your primary number, please re-enter.
*
Format: (000) 000-0000.
Work Phone
Format: (000) 000-0000.
Physical Limitations Asthma Diabetes Allergies etc andor special instructions Allergic to certain medications food allergies rare blood type wear contacts etc. Please type NONE if none.
*
Insurance Company
Group/Policy Number
Insurance Company Phone
Format: (000) 000-0000.
Please upload the FRONT of your insurance card
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of
Please upload the BACK of your insurance card
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Physicians Name
*
Physicians Phone
*
Format: (000) 000-0000.
City
*
State
*
Zip
*
Please indicate if you have required immunizations to attend a public school setting. Please answer Yes or No.
*
Please indicate if you are not immunized due to religious beliefs. Please answer Yes, No or N/A.
*
ADULT SIGNATURE
*
Submit
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