Camper's First Name:  * Camper's Last Name:  * Gender: MaleFemale Grade in School Next Year: Going into 3rdGoing into 4thGoing into 5thGoing into 6th Parents/Guardians Names:  * Home Phone:  * Cell/Work Phone:  * Address: City: State: Zip Code: Emergency Contact Name:  * Emergency Contact Phone:  * Emergency Contact Relationship to Camper:  * Church Registering with:  * 2 Choices for Cabin Mates: Every effort is made to place campers with a friend if possible. They must be in the same grade group (3rd/4th) or (5th/6th) By checking this box the Camper and Parents agree to comply with the rules and regulations of the camp stated on the previous page. Date of last tetanus shot:  * Has the camper had any problems with the following: Asthma Heart Problems Epilepsy Diabetes Fever If Yes please explain: Is the camper currently being treated for any illness or medical problems? Yes No If Yes please explain: Is the camper currently taking any medications? Yes No If Yes ALL medications must be turned in to the burse please obtain Medical Instruction form from your Church Office. It is also provided on the main camp download page. Does the Camper have any alergies? If so please list what and medications. My child may be administered the following medications by the Camp Nurse: Tylenol Ibuprofen(Advil) Pepto-Bismol Benadryl Additional info for the camp nurse about your child: IN CASE OF EMERGENCY: Insurance Comapny:  * Policy Number:  * By checking this box you are agreeing that if for any reason medical or disciplinary the camper named in this application needs to be sent home early you agree to pick them up at the camp no matter what the time night or day. Security code:   * Do not enter anything in this field:

* indicates a required field