Registration Information:  
   
Name ________________________________  Birthdate ___/___/___   Grade ________  Male / Female 
 
Address ___________________________________ City ___________________ State ____ Zip ______
  
Parent Name _______________________________________   Home Phone _____________________
 
Parent Email ________________________________________  Work Phone _____________________ 
 
Emergency Contact Name ________________________________ Emergency Phone ______________
 
Home Church ______________________________________ Town _____________________________
 
Program I Am Registering For: _________________________________ Program Date: _____________

Payment Information:
   
Deposit Enclosed: $ __________ ($25 registration fee required)
 
Method of Payment:      Check/Money Order_____     Visa_____    MasterCard_____     Discover_____
 
Card # ____________________________________ Expiration Date ___/___/___ Zip Code _________
 
Amount to Charge _____________  Card Holder Signature____________________________________

Health History & Insurance:
   
1. Date of Last Health Examination _________________ (within 2 years)
 
2. Immunizations:  DPT: Y / N,  Measles-Rubella:Y / N,  Polio:Y / N,  Date of Tetanus Shot _________
 
3. Skin Diseases:  Y / N,   If Yes, please explain ____________________________________________
 
4. Allergies: Food, drugs, hay fever, insects:  Y / N,   If yes, please explain _______________________
 
5. Medications & Treatments: List all current or ongoing treatments or medications, including dosage.
  
   _________________________________________________________________________
 
 6. List any illness, chronic conditions, or physical condition the camper has that requires restrictions
  
    on camp participation ( including past medical history) _____________________________________
        
7. Physician's Name ____________________________________ Office Phone __________________
      
8. Insurance Co. ________________________________________ Policy  ______________________
       
    Subscriber's Name ________________________________________________

To the best of my knowledge all registration and health information for the person described herein is correct.  I give permission for my child to participate in all camp activities, including the Cooperative Course and day trips off-site in camp vehicles, except as noted here:____________________________ and agree that the camp or its staff will not be held responsible for accidents or personal injury arising therefrom. I authorize the medical personnel or staff selected by the camp director to secure any medical or emergency treatment deemed necessary for the person named above. The camper’s parent / guardian is the primary carrier of accident / health insurance. I grant permission for photos and/or videotape taken of my child while at camp to be used in camp publications/promotional materials.
  
______________________________________      ____________
Signature of Parent/Guardian or Adult Camper            Date