Kids Camp Camper Registration

***All forms of payment will go directly to your church***

Name of Child *

First Name Last Name

Age *

Grade Just Finished *

Sex: *

Male Female

Church

Address *

Street Address

Street Address Line 2

City State / Province

Shirt Size

Y-Small A-Small Y-Medium A-Medium Y-Large A-Large A-Xlarge

Name of Guardian *

First Name Last Name

Phone Number *

Area Code Phone Number

E-mail

Allergies/restrictions *

Medications (If bringing Medications you must have it in the prescription bottle it came in. Put all medicine in clear baggie with child's name on it) *

Physical Limitations

Last Tetanus Shot *

Month Day Year

Emotional/Behavioral Needs

Do you have health insurance? *

Yes No

Insurance name and policy number. If none put NA *

A lot of pictures are taken at camp and shared with others to enjoy. Each kid goes home with a camp photo as well as a photo of his or her cabin. These photos are often used to promote camp for following years. If you DO NOT want your child’s photo to be used for any kind of promotion for future camps please check here *

Yes, it is ok to use my child's photo in promotion of future camps

In the event that I cannot be reached in an emergency during the dates specified on this form, I hereby give my permission to the physician or dentist selected by the church leadership to hospitalize, to secure proper treatment and / or injection, anesthesia, or surgery for my son or daughter as deemed necessary. Every activity is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By signing this form, the parent or guardian agrees to assume and accept all risks inherent in church related social activities. They also agree not to hold this church or its employees or volunteers liable for damages, losses, or injuries to the person or property undersigned. The parents or guardians understand that they are signing for the minor listed on this form and the signature is for both a medical and liability release. (Signed by Parent/Legal Guardian) *

First Name Last Name Date

------------Extra Information-------------

Is there anything specific about your child we should know that will help us give him or her a great time at camp?

Will you be visiting any days?

If so, what days? Will you be eating meals with us? And will you have any young children you will check in with the precamers? If so, please make sure you fill out a registration form for them (Cost will be $10 per day).

Kids Camp Camper Registration - $155 7/15/2019-7/19/2019