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Youth Summer Camp Registration Form
August 3-6
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* Indicates required question
Church Name (e.g. Covenant, Faith, etc.)
*
Your answer
CAMPER INFORMATION
Camper's Name
*
Your answer
Birthdate
*
MM
/
DD
/
YYYY
Grade (going into Fall of 2021)
*
Your answer
Gender
*
Female
Male
Sweatshirt Size
*
Adult S
Adult M
Adult L
Adult XL
CONTACT INFORMATION
Email
*
Your answer
Phone number
*
Your answer
Address
*
Your answer
What is the best way to reach you?
*
Your answer
MEDICAL INFORMATION
Primary Care Physician
*
Your answer
Physician's phone number
*
Your answer
Medical Insurance Provider
*
Your answer
Policy Number
*
Your answer
Group Number
*
Your answer
Have you had a Tetanus shot in the past 7 years?
*
Yes
No
Medical History, choose any that apply for your camper
*
Asthma/Respiratory
Allergies
Headaches
Diabetes
Cardiovascular
Blood Problems
Muscular/Skeletal
Skin
Gastrointestinal
Psychiatric
Other
None of the Above
Required
Please list details of anything you checked above
*
Your answer
Please list any medications that will be taken during the camp
*
Your answer
Please list any food allergies, dietary needs or other special instructions
*
Your answer
Does this camper have any other health or medical issues that would hinder their participation in any activity?
*
Your answer
PLEASE MAKE SURE TO FILL OUT THE SEPARATE WAIVER FORM :)
(found on the main Summer Camp Webpage)
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