Retreat Registration - Path of Life Camp

2012 Retreat Registration Form

Required Camper's Name:	MaleFemale
Camper's Birthdate:*	(MMDDYYYY)
Address:*
City:*
State:*
ZIP code:*
Phone:*	(2223334444)
Email:
Church:

Please select the retreats your child is planning to attend:*

February 10–11	Winter Teen Retreat
March 9–10	Winter Junior Retreat
April 20–21	Spring Junior High Retreat
October 12–13	Fall Junior Retreat
November 9–10	Fall Teen Retreat

Medical Questionnaire:

Does your child have any allergies to medications?* If yes, please explain:	YesNo
Does your child have any allergies to food products?* If yes, please explain:	YesNo
Does your child have any allergies to environmental elements such as insect bites?* If yes, please explain:	YesNo
Does your child have any special needs we should know of to accommodate their stay with us?* If yes, please explain:	YesNo

If necessary, do we have your permission to give your child:*

•Motrin	YesNo
•Pepto-Bismol	YesNo
•Topical Benadryl	YesNo
•Tylenol	YesNo

Health Insurance:
Check this box if you would prefer to bring your child's insurance information to registration.

Name of health insurance policy holder:*
Insurance policy number:*
Company:*

Parent/guardian contact information
I can be reached at:

Cell:	(2223334444)
Work:
Other:

Medical Requirements: If your child has medication(s) that need to be administered while
at the retreat, please see here for information on camp medical requirements

In case of emergency: I understand every effort will be made to contact me. However,
if I can not be reached, I give permission for the physician selected by the camp director
to secure proper medical treatment for my child.

By submitting this registration: I give my permission for the camp to use my child's
photograph in camp promotional information.