Amazing Grace Baptist Camp

Event:

Camper Information

First Name Last Name Email Address Birth Date Age Gender Address City State Zip Code Home Phone Work/Cell Phone Emergency Contact Emergency Phone Church/Group Pastor/Leader Pastor/Leader Phone Parent/Guardian

Medical Information

This form is required by all campers 18 years and younger and phone confirmation may be apart of this process.

Date of Tetanus Booster Any Prescribed Medication Specific Allergies Reactions to Allergies Asthma? Insurance Company Insurance Company Address Insurance Policy # Family Physician Physician Phone #

Immunization: please check all that have been administered to your child in the past.

DPT MMR Small Pox Typhoid Chicken Pox Any others not included:

Are there any activities that your child should not participate, due to his medical background?

In case of Emergency

I understand that every effort will be made to contact the parents or guardians. In the event that I cannot be reached, I hereby give permission to the physician selected by Amazing Grace Baptist Camp to hospitalize and secure proper medical treatment for, and order injection, or anesthetic, or surgery for my child as named on this form. I realize my insurance will be billed for any medical treatment as the primary coverage for my child.

By typing my name, I agree to this statement:

Online Parental Signture

This confirms that you, the parent have read this registration and agree that all information is correct. By typing your name you agree to release your child.

Parental/Guardian Signature Date Child Camp Dates Cabin Requests Phone Where you can be reached?

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