txac youth & young adult ministries early fall 2013 | Page 13
Camper Registration Form
Last
Fill out completely; print or type; Black Ink Only
Camper's legal name: _________________ ________________ _______________
First Middle
Forest Glen Christian Camp 6th Grade Event November 1-3, 2013
Circle One:
Preferred Name:________________ Birthdate:______________ Gender:_______ Name of one requested roommate:_________________________
Male/Female
Adult T-shirt size: S M L XL XXL Please indicate any allergies, special conditions, restrictions, medications:
_________________________
Home address
City
__________________
State
______ __________
Zip
Parent/Guardian Legal Name:___________________________________________ ( (
Home telephone Alternate telephone Name
**medications & prescriptions for camper must be in original bottle/container**
) )
Father's work telephone Alternate name
(
)
Mother's work telephone Relationship
(
)
Date of last Tetanus immunization: Family Physician:___________________________________________________ Physician's telephone number: ( Health Insurance Co.: ) _________________________________ Policy #:
__________________________ _________________
Church:___________________________ ____________________ ___________
City District
Please indicate any emotional, behavioral, or physical disabilities which may require special supervision. Your answer will not result in exclusion from camp except in matters of safety. This information will be made available to the camp coordinator, nurse, registrar, and your child's camp director and counselor to further enrich your child's summer camp experience.
Health Insurance Co. Contact Telephone # (____)__________________________ In case of emergency, I hereby give permission to the physician selected by the camp to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for the person named above. X_________________________________________ Signature of parent or legal guardian ________________ Date
Camper's transportation home will be by: _____ Church van _____ Parent/Guardian _____ Other_________________ Name of Driver(s)____________________________________________________ NO CHILD MAY BE RELEASED EARLY FROM CAMP EXCEPT TO PARENT OR LEGAL GUARDIAN. LETTER OF RELEASE IS REQUIRED. Parents: Check for accuracy and legibility of information and for signatures: THIS IS A LEGAL DOCUMENT