PD Day Camp September 28, 2026

PD Day Camp September 28, 2026

A Ministry of The Village Chuch at the Advent Christian Village
Camper Registration
Child’s Name
Grade
Students Sixth grade and up will participate as helpers for classes and other activities.
Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Parent’s Name
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Alternate Phone
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
People Who May Pick Up the Child
Parent’s Signature (Photo/Media Permission)
Health Form
Camper Last Name (Health Form)
Camper First Name (Health Form)
Emergency Contact Name
Emergency Contact Home Phone
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Camper
Emergency Contact Work Phone
Please enter a valid phone number.Format: (000) 000-0000.
Personal Physician
Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Insurance Company
Policy Number
Insurance Company Address
Medications Required on a Regular Basis
Allergies/Physical Restrictions
Dietary Restrictions
Medical Consent
Parent/Guardian Print Name (Medical Consent)
Parent/Guardian Signature (Medical Consent)
Date (Medical Consent)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
OTC Medication Permission
Daily Medication at Camp
List Daily Medications While at Camp
Health History
General Health History

Other Medical Concerns
Explain Yes Answers (General Health History)
Date of Last Physical

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Mental/Social/Emotional Health

Other Mental/Emotional Health Concerns
Explain Yes Answers (Mental/Social/Emotional Health)
The Village Church leaders have permission to photograph/film the minor(s) designated above in any manner or form for any lawful purpose associated with this camp.
Should be Empty:

PD Day Camp September 28, 2026

Camper Registration

Health Form

Medical Consent

Health History