Name _______________________________________________________________ ___ Male ___ Female Age _____ Date of Birth ____/_____/_____ Address ______________________________________________________________ City ___________________ State ____________Zip+______________+__________ I live with: (Please Circle) Parent / Guardian / Other, Mr. & Mrs. / Mrs. / Mr. / Ms. 1st parent ___________________________________________________________ Home Phone (___)___-____ Work Phone (___)___-____ Cell Phone (___)___-____
2nd Parent
______________________________________ Phone
(___)_____-____
I will be picked up by:
___________________________________________________
Emergency contact
(not in same home):
____________________________________
Relationship
________________________________ Home Phone (___)____-____
Work Phone (___)___-______ Cell Phone ( __ )____-______
Church Name
________________________________________________________
Pastor ________________________
Group Leader _________________________
Address ______________________________________________________________ City ___________________ State ____________Zip+______________+__________
I also understand and
agree to abide by all the camp policies and any
restrictions my parents have stated.
Camper Signature __________________________________Date ___/_____/_____
The above information
is correct to the best of my knowledge. He/she has
permission to engage in all camp activities. I hereby
give permission to the medical personnel selected by
camp director to order X-rays, routine tests, treatment,
and necessary transportation for my child. In the event
I cannot be reached in an emergency, I hereby give my
permission to the doctor selected by the Camp Director
to secure and administer treatment, including
hospitalization for my above-named child. I further
release Cedine from all liability beyond the accident
insurance carried by the camp. Furthermore, I understand
that pictures will be taken during my child's time at
camp, and I give my permission for the use of such
pictures containing my child's likeness (and/or my
likeness) for the promotion of Cedine's camp or
conference ministry.
Guardian Signature _________________________________Date ___/_____/_____
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