Breakaway Teen Camp 2019
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Camper Personal Information
First Name *
Middle name *
Last name *
Preferred name
Birth date *
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Gender *
Grade (Grade completed during 2018-2019) *
Address 1 *
Postal code *
City *
State *
Home phone (Use cell phone if you don't have one)
Cell phone *
Work phone (Not required)
Email address *
Select program type *
Parent / Guardian 1
First name *
Last name *
Gender *
Martial status *
Relationship status *
Employer (optional)
Camper lives with contact? *
Release camper to contact? *
Address 1 *
Postal code *
City *
State *
Home phone (Use cell phone if you dont have a home phone)
Cell phone *
Email address *
Parent / Guardian 2
First name
Gender
Clear selection
Marital status
Clear selection
Relationship to student
Occupation
Employer
Camper lives with the contact?
Clear selection
Release camper to contact?
Clear selection
Address 1
Postal code
City
State
Home phone
Cell phone
Email address
Emergency contact
First name *
Last name *
Gender *
Martial status *
Relationship to student *
Occupation (optional)
Employer (optional)
Camper lives with the contact? *
Release camper to contact? *
Address 1 *
Postal code *
City *
State *
Home phone (use cell phone if you dont have one)
Cell phone *
Email address *
Camper Profile Sheet
I am the parent/guardian of this student being registered for camp *
Church city / Church name
Clear selection
Leaders name
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Insurance carrier *
Coverage start date *
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Coverage end date *
MM
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DD
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YYYY
Insurance co phone number *
Insured's name (First, last) *
Insurance policy *
Group number *
Does the camper have any allergies?
Clear selection
If yes, please explain
Diptheria *
MM
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DD
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YYYY
Whooping cough *
MM
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DD
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YYYY
Polio *
MM
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DD
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YYYY
Tetanus Toxoid *
MM
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DD
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What communicable diseases has this camper had? *
Required
Does the camper have *
Required
Is there any information we should have regarding the welfare of this camper? (disabilities, restrictions, etc?) *
Disclaimer and acknowledgement (Parent / guardian signature) *
I do hereby state that I have legal custody of this child, a minor, who resides with me. While this minor is a registered ca,per at any Illinois assemblies of God summer camp, I hereby authorize any director, counselor, nurse, dean, lifeguard, or other responsible person of said camp to consent to any x-ray, examination, anesthetic, medical, or surgical treatment, and hospital care, to be rendered to this minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the united states, when such medical or surgical treatment is necessary. I also give permission for my child to receive over-the-counter medication from the camp nurse if necessary.We give full permission to the Illinois assemblies of God summer camps to reproduce any photograph and/or video image of me/my student for promotional usage without obligation to me/my student. We have read these rules and agree to abide by them and do hereby give permission to participate in all camp activities *By typing my signature, this holds the same legal value as a handwritten signature
Todays date *
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Student acknowledgement (Student signature) *
Regulations are given as guidelines for every camper to follow. This code of conduct, which can be found on the ISM camp webpage, has been established for your protection and the benefit of every person present. The lack of cooperation, unnecessary roughness, lack of respect for property or an unwholesome attitude on the part of any camper will result in expulsion from the camp. The expense of transporting the expelled camper(s) home is the responsibility of the parent/guardian
Today's date *
MM
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Medication list 1
Medication name
Strength
Route
Quantity per Dose
Dosage
Reason
Comments
Add a schedule for what days / times the student needs this medication
Over the counter Medications
The following over-the-counter medications may be given to my camper
Comments (Special instructions or allergic reactions)
Medications list 2
Medication name
Strength
Route
Quantity per Dose
Dosage
Reason
Comments
Add a schedule for what days / times the student needs this medication
Over the counter Medications
The following over-the-counter medications may be given to my camper
Comments (Special instructions or allergic reactions)
Medications list 3
Medication name
Strength
Route
Quantity per Dose
Dosage
Reason
Comments
Add a schedule for what days / times the student needs this medication
Over the counter Medications
The following over-the-counter medications may be given to my camper
Comments (Special instructions or allergic reactions)
T Shirt
Size / Price
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Submit
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