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Merge Camp
Registration Packet for Campers
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* Indicates required question
Email
*
Your email
Last Name of Camper
*
Your answer
First Name of Camper
*
Your answer
T-Shirt Size
*
YS
YM
YL
S
M
L
XL
XXL
Other:
Street Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip
*
Your answer
Gender
*
Male
Female
Grade going into fall of 2019
*
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Primary Parent / Guardian Name
*
Your answer
Primary Phone Number
*
Your answer
Secondary Phone Number
*
Your answer
Emergency Contact
*
Your answer
Primary Phone Number
*
Your answer
Secondary Phone Number
*
Your answer
Name of Physician
*
Your answer
Phone Number
*
Your answer
Medical / Insurance Carrier
*
Your answer
Policy / Group Number
*
Your answer
Date of Last Examination
*
MM
/
DD
/
YYYY
Name of school where CURRENT records are kept:
*
Your answer
Chronic / Recurring Conditions... Check all that apply:
*
asthma / respiratory problems
bleeding / clothing
kidney disease / bed wetting
constipation
hearing impairment
ear infection
epilepsy
seizures
heart disease
diabetes
sickle cell trait or disorder
special diet
hypertension
headaches
fainting
other
N/A
Required
If other, please list:
Your answer
Food Allergies:
*
Your answer
Medicine Allergies:
*
Your answer
Restricted Activities... Check all that apply:
*
Swimming
Outdoor activities such as walking and running
Ropes Course / Climbing
Other
N/A
Required
If other, please list:
Your answer
Will you be taking medication at camp? All medication must be in the original container and administered by the camp nurse.
*
yes
no
Check all the over counter medicine approved to be administered AS NEEDED by the camp nurse:
*
Tylenol (acetaminophen)
Benadryl (diphenhydramine)
Motrin (ibuprofen)
Creams for burns, scraps, insect bites
Any other over-the-counter, non-prescription medications or applications, not to exceed recommended dosage
Required
List Exceptions
Your answer
Which fundraising events will your child be participating in:
*
Gift card raffle: March 24th - April 7th
Wiffle ball tournament: June 1st
Mini golf scramble: July 13th
None
Other:
Required
Type name for consent... I hereby certify that I as a leader or I as a parent / guardian give my consent of participation of Merge Camp 2019. I agree and to hereby waive and release all claims against Merge Community Church and any sponsor or other person engaged in Merge Camp and agree to hold them harmless from any and all liability. I hereby give the authority to the designated personnel of Merge Community Church to consent to medical treatment in the event medical attention becomes necessary. This authorization includes the authority to sign releases on my behalf for medical services. The foregoing to whom I give such authority is a religious institution and I will be financially responsible for any cost incurred for medical treatment.
*
Your answer
Date:
*
MM
/
DD
/
YYYY
Time:
*
Time
:
AM
PM
Send me a copy of my responses.
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