Family Camp Registration Please Read Family Name Child's Name First Name Last Name ATTENDING Parent or Guardian First Name Last Name Phone (###) ### #### ATTENDING Adult other than parent First Name Last Name Phone (###) ### #### Email * Address Address 1 Address 2 City State/Province Zip/Postal Code Country Person responsible for picking child up on Saturday at 1:30 (if applicable) Church Name Pastor's Name There will be photos and video taken at camp. Some of which will be used in future promotional ads, and or video. I understand the camps photo and video policy HEALTH REGISTRATION Are you (camper) under the guardianship of the court, government agency or foster ? Yes No Please check if you have had a history of any of the following, (any medical history?) Asthma Heart trouble Sinus trouble Ear trouble Bed wetting Diabetes Frequent colds Allergies Athletes foot Upset stomach Kidney trouble Sleepwalking Epilepsy Emotional difficulty If Allergies are checked, please specify to what Please List Any Medications Authorization to use these over-the-counter meds: Ear Drops Eye Drops Ibuprofen Tylenol Antacid Dietary restrictions: Activities that should be restricted Family Doctor Name & Phone Number In case of Emergency, I understand that the people listed above will be notified if possible and I hereby give permission to the Physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child (or myself) as named above. NOTE: Laclede Baptist Camp insurance is a secondary insurance. The camper’s insurance is primary insurance. Name of camper’s insurance Phone Number / Policy Number / Group Number Thank you!