Camp Good News: Lake Pickerel

Camp Good News Registration Form
Week Attending
Camper's Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Grade
Going in to grades 1-7
Gender
Parent/Guardian

First NameLast Name
Address

Street Address

Street Address Line 2

CityState

Postal Code
Email
example@example.com
Request a Cabin Mate
Requesting a cabin mate doesn't guarantee that you will bunk with them.
If someone other than a parent is picking up a camper or if there are any special pickup instructions, please list them here.
If a child to leave the camp facilities they must be named by a parent or guardian before check in

Emergency Contact Information
Name

First NameLast Name
Relationship to Camper
Address

Street Address

Street Address Line 2

CityState

Zip Code
Best Emergency Phone Number

Area CodePhone Number
Relationship to Camper
Health Insurance Company
Policy Number
Date of Camper's Last tetanus shot or booster

MonthDayYear
Date
Special Diet Requirements
Allergies
List any medical conditions which may affect the camper's stay
All medication including non prescription, must be checked in the first day of camp to the medical staff. All medication must be in the original bottle. prescription medications will only be administered according to written prescription unless doctor's note indicates otherwise.
Medications (Both prescription and non-prescription)

In case of a medical emergency, I understand every effort will be made to contact parent/guardian of campers. In the event I cannot be reached I hereby give permission to the medical staff selected by the camp director to hospitalize, secure proper treatment, and to order injection, anesthesia, or surgery for my child. Parent/Guardian(s) are responsible for the insurance coverage while their child is attending camp. Any outside charges incurred relating to sickness or illness by your child will be billed to parent/guardian(s).

HIPPA Statement

I authorize Child Evangelism Fellowship to discuss my child's health information with camp volunteers and healthcare providers as necessary.

Designated medical staff will be present to administer medications and in case of emergencies. The camp has permission to administer Tylenol, Ibuprofen, over the counter topical medications, to my child as needed.

I consent to have my child participate in the activites of Child Evangelism Fellowship, Inc., Child Evangelism of SD, Inc., and Camp Good News and certify that I will hold CEF and Camp Good News, its directors, employees, or agents harmless from any of all liability and claims arising out of participation in or in connection with the program of Camp Good News.
Date

MonthDayYear
Date
Photo Release

Child Evangelism Fellowship® may, from time to time, document the activities of
the ministry with photographs or videos. I hereby assign and grant to Child
Evangelism Fellowship Inc., its subsidiaries and successors, and assign the
unqualified right to the ownership, use and proceeds of all photographs or video of me or my minor child, without reservation or limitation, including use of
photographs or video of me or my minor child for, but not limited to, advertising,
educational and promotional purposes.
Authorized Parent/Guardian Signature

First NameLast Name
Should be Empty:

Camp Good News Registration Form

Emergency Contact Information