2010 Camp Registration Form

Personal Information:

* denotes required fields
Male Female
*First Name:
*Last Name:
*Address:
Contact Email:
*City:
*State:
*Zip:
Home Phone:	(xxx) xxx-xxxx
Cell Phone:	(xxx) xxx-xxxx
*Age:
*Birthdate:	mm/dd/yyyy
*Grade Entering:
Church with whom you will be attending(if any):

Medical Information:

Please check if the camper has or is susceptible to the following:

Heart Murmur Epilepsy/Convulsions Diabetes Asthma Ear Infection
High Blood Pressure Heart Disease Recent Head Injury Hay Fever

Does your child have any current medical problems or restrictions on activities?

Yes No

If yes, please explain:

May your child be given Advil or Tylenol? Yes No

Camper Allergies

Poison Ivy Mosquitoes Bees Penicillin Other

If Other:

All medicine is to be left with and dispensed by the first aid caregiver!

Health Insurance Company:
Policy #:

In case of emergency, I hereby give permission to the physician selected by the camp management to give treatment and medication to my child. I understand every effort will be made to contact me before treatment is given. I hereby give my child permission to take part in the recreational program, swimming and other activities. I hereby release the camp from any responsibity other than normal supervision and care. In case of accident, I will not hold Camp Samuel or its staff members, management or officers liable unless guilty of negligence.

I agree

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