Path of Life Camp

2010 Registration form

 

NAME:___________________  Sex:  M /  F

 

Address:___________________________________

 

City__________________ St _______  Zip_______

 

Phone________________ Email________________

 

Church ______________________

 

Please Circle the dates you plan to attend

#1 June 28-July 2: Day Camp #1 Puppet Week

#2 July 4- 10: Junior Week #1 Knights Week 

#3 July 11-17: Teen Week Taming the world

#4 July 19-23: Day Camp #2 Farm Days

#5July 25– 31: Junior Week #2 Circus Week

#6 August 2-6: Day Camp#3 Western Week

#7 August 8-14: Jr. High Camp Horse Week

#8 August 16-20: Day Camp #4 Amazing Animals

Health Form (Please fill out completely)

 

Name of Insurance Policy holder

 

____________________________

 

Insurance policy number and company

 

____________________________

Medical Questionnaire for Registration

1 Does your child have any allergies to medications?

 

Yes    /     No

 

2 Does your child have any allergies to food products?

 

Yes    /     No

 

3 Does your child have any allergies to environmental elements like insect bites?

 

Yes    /     No

 

4. If necessary do we have your permission to give you child

 

             Tylenol                                       Motrin

             Topical Benadryl                      Pepto bismol

 

5. Does your child have special we should know of to accommodate their stay with us?

 

 

6. State law requires that we have information regarding your child’s immunizations. If you have not provided it with the camp registration, we will be happy to photo coy their record and attach it to this form.

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

 

The resident camp registration fee of $40.00 must accompany this registration form and is non-refundable. For an early this discount, this form must be postmarked by May 30th.

 

By Submitting this registration I give my permission for the camp to use my child’s photograph in camp promotional information.

 

I can be reached at:

 

Cell ____________________

 

Work ___________________

 

Other___________________

 

 

Parent or legal guardian’s

 

 

Signature________________________