Youth Group Health Form

Youth Group Health Form

Only complete this form if your camper is attending camp with his or her church group. One form per camper.
Camper Information
Camper's Name*

First NameLast Name
Camper's Address*
Mailing Address
City & State*
Zip Code*
Select camp session:*

Junior Camp 1Junior Camp 2Junior Camp 3Middle School CampSr High CampAllstar CampWinterpalooza
Who are you coming to camp with?*

Ballard ChurchBeliever's FellowshipCalvary Baptist Church of RoyChurch on the HillThe Bridge Christian FellowshipChristian Church of WarrentonDamascus Community ChurchEpic House ChurchEpic Life ChurchGrace ChapelHope FellowshipLCOP/Lakewood GraceMarine View PresbyterianMountain View Community ChurchNew CommunitySequim Community ChurchSmokey PointSouth Beach ChurchUniversity PresbyterianWestside Community Church
Gender*

MaleFemale
Grade*
2025-26 school year
Birth date*
mm/dd/yyyy
Age*
on the first day of camp
Contact Information

In case of emergency, list the primary contact person first, followed by up to 3 other people who may pick up the camper(s). At sign-out, one representative from each church will sign-out all of the campers from his or her group.
Your Name and Information*

First NameLast Name
The best best number to reach you*

Area CodePhone Number
Your Email*
example@example.com
Your relationship to the camper*
Who else is authorized to pick up this camper from camp? (church representative is already included)*

First NameLast Name
Phone Number*

Area CodePhone Number
Relationship to the camper*
Add Another Contact
Name

First NameLast Name
Phone Number

Area CodePhone Number
Relationship to the camper
Camper Health Information
List any Allergies
Additional Dietary Restrictions
With advance notice, we can provide: Gluten Free, Dairy/Lactose Free, OR Vegetarian/Vegan meals (but only one of those options at a time). Our menu can also be modified to exclude such common allergens as tree-nuts, peanuts and shellfish.
Is the camper's tetanus booster current?

YesNo
Specify if any of the following medications may be administered to your camper: Tylenol, Motrin, Benadryl, Tummy Soothers, Cough Suppressant, Anti-Itch Cream, Cold Medicine

All listed may be administeredNone listed may be administeredOther
Will this camper be bringing any medications (over the counter or prescription) to camp?

YesNo
You will need to bring a medication administration report (separate form) with you to camp. All medications must be in their original containers and turned in to the nurse.
Please explain any health concerns (asthma; diabetes; frequent colds, sore throat or ear aches; heart, kidney, or lung trouble; etc.):
Describe any behavioral concerns, activity restrictions, or anything else that would be helpful for the camp nurse and/or counseling staff to know.
Camper's Doctor
Doctor's Phone #

Area CodePhone Number
Health Insurance Company
Group #
ID #
Statement of Consent
"In case of injury or illness, I hereby give consent for hospitalization or medical treatment by a licensed medical doctor when deemed necessary by the camp for the welfare of said minor (or self, if 18 or older). I understand every effort will be made to notify parents or guardian of child. I acknowledge that I have given complete, accurate information and understand the camp's policies."

I agree with the above statement and am authorized to give such consent for each child listed above.
Initial here.*
Activities Waiver
Submitting a registration form to Black Lake Bible Camp implies agreement with the Activities Waiver (release of liability, assumption of risk and indemnification agreement) found on the Camp Policies page of our website and gives permission for each registered camper to participate in all camp activities.

Parents/guardians may deny participation in specific activities with the opt out form on this page.

I understand the activities waiver and I am authorized to give such consent for each camper listed above.
Initial here*
Behavior Policy
We are excited to welcome your child to BLBC this summer! We are kindly asking parents to explain the following safeguarding behavior protocols to your child before they arrive at camp.

At BLBC, we are kind and treat everyone with respect. At BLBC, Staff, Volunteers, and Campers NEVER:

-Use words that are meant to shame or belittle someone else;
-Touch anyone on a part of their body that is private;
-Spend time alone with another person – out of sight of others;
-Ask anyone to lie.

At BLBC, we ALWAYS tell a Cabin Leader if anyone makes us or a friend feel uncomfortable. BLBC’s Leadership Team will ALWAYS take action to keep you safe.

If your child ever feels unsafe at camp, please contact us immediately. Our Safeguarding Advisor, Melanie Ewert, Melanie.ewert@Blbcolympia.com, is available to answer any questions.
Initial Here*
Food Allergies

Unfortunately, we cannot fully guarantee a cross-contamination free or allergy free kitchen and dining hall. There is always a risk of contamination from the producer, manufacturer, to our kitchen. Those who are concerned with food allergies need to be aware of this risk. BLBC will not assume any liability for adverse reactions to food consumed, or items one may come into contact with while eating a BLBC.
Initial Here*
Media Release
I grant Black Lake Bible Camp permission to use comments, images, and/or recordings of the person/s you are registering in our promotional materials which may appear online or in print.
Please select one:*

I consent to the media releaseOpt-out: I do not want my child to appear in promotional materials from Black Lake Bible Camp
Connect with BLBC
If you are interested in learning more about BLBC, please check all that apply.

I would like to subscribe to BLBC's weekly Letter from the Lake.I would like to know more about BLBC's giving programs.I would like to learn more about volunteer opportunities at BLBC.
Should be Empty:

Youth Group Health Form

Camper Information

Contact Information

Camper Health Information

Statement of Consent

Activities Waiver

Behavior Policy

Food Allergies

Media Release

Connect with BLBC