2025 QSRR Camp Registration (ADULTS)

2025 Queens Section Royal Rangers
Camp Registration & Medical Release Form
ADULTS

Please note: This form is for adults 18 and over.
Adults are male leaders, or guests who are staying on camp for the weekend.
Registration Information
Name (First/Last)*
Date of Birth (mm/dd/yyyy)*

MonthDayYear
Date
Address*

Address

Street Address Line 2

CityState

Zip Code
Email Address*
example@example.com
Outpost*
Leader or Guest*
Leader - Chartered Leader of the Outpost Guest - Adult 18+
* Leaders are men who work in the local outpost; Guests are men who are assisting the outpost for the weekend: Pastors, van drivers, fathers, etc. Boys who graduated from high school in June are considered leaders, regardless of age.
Emergency Information
Emergency Contact Name (First/Last)*
Relationship*
Preferred Phone Number*
Medical Information
Any known allergies illness injuries or disabilities*
Current Medications*
Date of last Tetanus Booster (mm/dd/yyyy)*

MonthDayYear
Date
Physician Name*
Physician Phone Number*
Insurance Information
Insurance Company*
Insurance Phone Number*
Policy Holders Name*
Policy Number*
Authorization & Consent
I, hereby give my consent/authority for any medical attention, in the event of an accident, injury, sickness, etc., under the direction of the person(s) listed, I understand that every effort will be made to notify my emergency contact as soon as possible. I also assume the responsibility for the payment of any such treatment. This release is effective for the Queens Royal Rangers Sectional Camp August 1-3, 2025. I will not hold the Queens Royal Rangers, Spanish Eastern District, or Camp Koinonia liable for any accident that may occur.
Name*
My signature*

Clear
Signature Date (mm/dd/yyyy)

MonthDayYear
Date

Payment*

2025 Queens Section Royal Rangers Camp Registration Fee

$55 Quantity

Enter coupon

Payment Methods

Credit Card

Apple Pay

Google Pay

Should be Empty:

Registration Information

Emergency Information

Medical Information

Insurance Information

Authorization & Consent

Payment Methods