Parent or Guardian Name  _____________________________

Home Phone ________________ Work Phone ____________

Emergency Phone ___________________________________

Address ___________________________________________

Special Medications __________________________________

Allergic Reactions ___________________________________

Physical Handicaps, Disorders, or Disease _________________

___________________________________________________

Restricted Activities __________________________________
Reasons ___________________________________________

Date of Tetanus Booster _________________ (please have up to date)

Insurance Co ________________________________________

Address ____________________________________________

In case of emergency,  I hereby give permission to the physician selected by the camp director or staff member in charge to hospitalize, secure proper treatment for, and to order injection, anesthetic or surgery for my child, as named on this application.  I certify that My child is in good physical condition and is able to participate in the entire camping  program other than activities listed as "restricted." I also certify that my child has no communicable diseases.

________________________________________________________________________________
Signature Parent or Legal Guardian                                      DATE

Name _______________________________________________________________________

Street _______________________________________________________________________

City  _________________________________ State _______________  Zip _______________

Phone (       ) ___________________________________________________________________

School Grade in September ________________________________________________________

Age ____________________________   Male (  )          Female  (  )

Date of Birth ___________________________________________________________________

Name of Church ________________________________________________________________

Full Name of Pastor ______________________________________________________________

Church Address _________________________________________________________________

City __________________________________ State __________________   Zip _____________

Phone   (        )  _________________________________________________________________