Youth Week Student Registration

Youth Week Student Registration
Group*
JH: Junior High | SH: Senior High
Student Information
Student name*

First NameLast Name
Gender*

MaleFemale
Date of birth*

MonthDayYear
Grade completed*
At time of attending
T-shirt size*

XSSMLXLXXLXXXL
Parent or Guardian Information
Parent or guardian with legal custody*

First NameLast NameRelation to student
Phone*
Format: (000) 000-0000.
Email*
Home address*

Street Address

Street Address Line 2

CityState

Zip Code
If the student must be discharged, who else has permission to pick them up?
Name(s) and phone number(s).
Secondary contact

First and Last NamePhoneRelation to camper
Health
Allergies
List any of the student's allergies and their reactions, if applicable.
Dietary needs

Gluten-freeDairy-freeVegetarianOther
Does the student have any physical restrictions limiting their participation?
Medications that you do NOT want given to the student to treat illness or injury

Acetaminophen (Tylenol)Ibuprofen (Advil, Motrin)Phenylephrine decongestant (Sudafed)Cough dropsAntihistamine/allergy medicine (Benadryl)Bismuth Subsalicylate for Diarrhea (Pepto-Bismol)
Treatment medication agreement

As the parent/guardian of the student, I give permission to administer any medications not selected above to the student on an as-needed basis to manage illness and injury, and release Harvey Cedars Bible Conference and/or the church's youth leader from liability for any damages the student may suffer as a result.

Medications the student will take during the week

Daily medication agreement

As the parent/guardian of the student, I request that the medication(s) described above be administered to the student, and release Harvey Cedars Bible Conference and/or the church's youth leaders from liability for any damages the student may suffer as a result.
Health care provider*

Rows Name Phone

Primary doctor

Rows	Name	Phone
Primary doctor

Insurance information*

Rows	Company name	Phone	Policy number
Insurance

Health History
Has/does the student:

Ever been hospitalizedHad eye surgeryHad any surgery recentlyHad a recent infectious diseaseHad asthma, wheezing, or shortness of breathHad seizuresHad fainting or dizzinessPassed out or had chest pain during exerciseHad mononucleosis in the past yearHad back or joint problemsTraveled outside the U.S. in the past 9 monthsHad a recent head injury or fractureBeen treated for ADD or ADHDBeen treated for emotional or behavioral difficultiesSeen a professional for mental health concerns in the past yearHad a major event effect them (abuse, death, family change, disaster, etc.)Have diabetesHave recurrent or chronic illnessesHave frequent headachesHave frequent diarrhea or constipationWear glasses, contacts, or other eyewearHave menstruation problemsHave sleeping or sleepwalking problemsHave bedwetting problemsHave skin problems
Explanation for ALL checked answers

Immunization doses (leave blank if not applicable)

Rows	Month/year
Diphtheria, Tetanus, Pertussus (DTaP)
Tetanus booster (dT/TdaP)
Mumps, Measles, Rubella (MMR)
Polio (IPV)
Haemophilus Influenza type B (HIB)
Pneumococcal (PCV)
Hepatitis B
Hepatitis A
Varicella (Chicken Pox)
Meningococcal Meningitis (MCV4)
Tuberculosis (TB)

Student Information