Medical Waiver
For anyone coming to a Manderley Signature Event
Contact Information
Camper/Guest Name
*
First Name
Last Name
Camper/Guest Email
*
example@example.com
Camper/Guest Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Camper/Guest Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Visit Information
Group Name
*
Please Select
Berean Baptist Church
Bible Baptist Church KY
Bryan College Athletes
Day Camp
Edgemont Baptist Church JR Camp
Edgemont Baptist Church TN 2
Enon Baptist Church
Fairview Baptist Church Paris TN
FBC Barberville
FBC Pikeville
Floyd Road Baptist Church JR
Floyd Road Baptist Church
Gardendale Baptist Tabernacle
Goodlettsville Pentecostal Teens
Grace Baptist Temple
Grand Camp
Lakeside Baptist Church
Maplewood Baptist Church
New Heart Christian Church
Philema Road Baptist Church
Southside Baptist Church
West Florida Baptist Church
West Huntsville Baptist Church
Name of your church, school, or camp
Event Name
*
Please Select
Breakaway
Man Camp
Junior Camp
Day Camp
Seasons Ladies Retreat
Teen Camp 1
Teen Camp 2
Teen Camp 3
Arrival Date
*
-
Month
-
Day
Year
Date
Departure Date
*
-
Month
-
Day
Year
Date
T-Shirt Size
*
Please Select
Child Small
Child Medium
Child Large
Adult Small
Adult Medium
Adult Large
Adult X Large
Adult XX Large
Adult XXX Large
Gender
*
Male
Female
TAG
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Any Food Allergies?
*
Yes
No
List Food Allergies
*
Doctor Note
*
Browse Files
Drag and drop files here
Choose a file
Upload a doctor's note listing food allergens
Cancel
of
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Emergency Contact
EC Name
*
First Name
Last Name
EC Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Is Guest aged 17 or younger
*
Please Select
Yes
No
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Minor Information
Please complete in full and to the best of your knowledge
Camper Birthdate
*
-
Month
-
Day
Year
Date
Camper Grade
*
Please Select
12
11
10
9
8
7
6
5
4
3
2
1
Grade just completed
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Insurance Information
Type of Insurance
*
Please Select
Family Health
Medical Insurance
Self Pay
Insurance Carrier/Family Medical Name
*
Name of Insured
*
First Name
Last Name
Relationship to Camper
*
Insurance/Group Number
*
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Medical Information
Immunizations Up to Date
*
Yes
No
Currently Taking Medication
*
Yes
No
Medications
Dosage
Chronic or Recurring Illness or Medical Condition
*
If none, type "None"
Any Activitiy Restrictions?
*
Please Select
Yes
No
Health or Medical Concerns
*
Please check one
*
I give permission for my child to receive over-the-counter medications as needed, according to the label directions.
I do NOT give permission for my child to receive over-the-counter medications
Unwanted Administered Medications
*
If permission is given, please list any specific medications you DO NOT want administered to your child
Insurance Card
*
Browse Files
Drag and drop files here
Choose a file
Upload both sides of Insurance Card
Cancel
of
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Guest Signature
*
Legal Name
*
First Name
Last Name
Parent/Guardian Signature 1
*
Parent/Guardian Name 1
*
First Name
Last Name
Parent/Guardian Signature 2
*
Parent/Guardian Name 2
*
First Name
Last Name
Submit
Should be Empty: