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Fall Retreat Registration/Release Form
Please fill out a separate form for each camper.
CAMPER NAME:
CAMPER DATE OF BIRTH:
CAMPER STREET ADDRESS:
CITY & ZIP CODE:
PARENT/GUARDIAN NAME:
PARENT/GUARDIAN PHONE:
EMERGENCY CONTACT:
NAME:
RELATIONSHIP TO CAMPER:
CONTACT NUMBER:
ALT CONTACT NUMBER:
INSURANCE INFORMATION:
INSURANCE NAME:
DOCTOR'S NAME:
POLICY NUMBER:
DOCTOR'S PHONE:
RELEVANT MEDICAL INFORMATION:
DOES THE CAMPER HAVE ANY MEDICAL ISSUES WE NEED TO BE MADE AWARE OF?
ANY KNOWN ALLERGIES?
Please Check Any Medications Your Child Can Be Given:
Tylenol
Ibuprofen
Laxative
Benadryl
Pepto Bismol
Sinus Tablets
Aspirin
Aleve
Tussin DM
Midol
PLEASE LIST ANY MEDICATIONS YOU ARE SENDING WITH CAMPER:
The information provided is correct to the best of my knowledge. The person herein described has permission to engage in all camp activities except as noted. My child will abide by the camp rules and follow staff directives. I hereby give my permission to the camp medical staff to secure the proper medical treatment for my child in case of injury or illness. I have read and understand the above release.
I agree to the terms & conditions
SIGNATURE:
Submit
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