KIDS SUMMER CAMP 2024

Attendee's Name(Required)

First Last

Attendees Address(Required)

Street Address Address Line 2 City State ZIP Code

Choose grade child COMPLETED in 2023-2024(Required)

Birthday(Required)

Gender(Required)

Male

Female

Does your child have any allergies, special needs, learning disability, or behavioral diagnosis you would like to share with us so that we are prepared to help him or her to feel safe as possible?(Required)

Parent/Guardian Name(Required)

First Last

Parent/Guardian Phone(Required)

Parent/Guardian Email Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Name of emergency contact(Required)

First Last

Phone Number of emergency contact(Required)

Relationship to attendee(Required)

Others Authorized to pick up your child(Required)

Name of Insurance Company(Required)

First Last

Insurance Company Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Insurance Company Phone Number(Required)

Insured’s Name(Required)

First Last

Policy Number(Required)

Group Number(Required)

Please list any past medical conditions we would need to be aware of including but not limited to: asthma, diabetes, eyes. Sinus trouble, ears, breathing, dizziness, nosebleed, kidney trouble, stomach upset, hay fever etc.(Required)

Any allergies?(Required)

Is the attendee currently taking any medication?(Required)

YES, they are taking medication

NO, they are not taking medication

If yes, please list medications

Is the attendee able to participate in recreational activities?(Required)

YES

NO

Do you attend a church? Yes or no(Required)

YES

NO

If yes , where do you attend?(Required)

How did you hear about our camp?(Required)

I give my permission for my child to be photographed.(Required)

YES

NO

SUMMER CAMP REGISTRATION

Please print the medical form, have it notorized, and bring it either to Ms. Tammy, Mrs. Lindy or to the church office.