Laclede Baptist Association Camp- Health Registration
We need a health form for each person staying at the camp (adults & children)

Please complete this form along with your camp registration for EACH Laclede Baptist Camp you plan to attend. 
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Which camp will you be attending?
Camper/Worker Name *
Age
Parent/Guardian (if applicable):
Address
City
State
Zip *
Home Phone
Cell Phone
Work Phone
In case of emergency notify: (other than parent)
Name
Phone Number
Are you under the guardianship of the court or government agency?
Clear selection
Please check if you have had a history of the following: *
Required
Instructions on any health concerns listed above:
Are you currently taking any medication? 
Clear selection
If yes, list medication(s) and dosage instructions:
Blood type: (if known)
Date of last tetanus shot:
MM
/
DD
/
YYYY
Activities that should be restricted:
Family Doctor
Family Doctor 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. (Please enter your full name)
NOTE: Laclede Baptist Camp insurance is only a secondary insurance. The camper's insurance is the primary insurance.

Name of camper/worker's insurance:
Phone number of insurance company:
Policy #
Group #
Submit
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