Inspire - Live AWESOME- Day Camp Registration

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Inspire - Live AWESOME- Day Camp Registration - at Unity Village, Missouri

For more information - visit here:

http://www.unityvillagechapel.org/2015-summer-camp.html

Family Information

Please give us information about your family - first and then each of your children.

Parent/Guardian Name *

(This should be the name of the person who is filling out this form.)

Email Address *

Please provide a valid email address.

Home Address *

Please provide a valid street address.

Home Address - City, State, Zip Code *

Please provide your city, state, and zip code.

Name of Church (If applicable)

Contact phone numbers during camp, (including area code):

(If the person is someone other than you, please list their name and relationship.)

Try this number first *

Try this number second

In emergency, if I cannot be reached, please contact, this person. *

Please list their name and relationship.

Please contact the emergency person at this phone number. *

Please include the area code.

First Youth Information

Please list each child separately, until you are at the Final Confirmation Page.

First Youth's Name *

First and Last Name

Relationship to you *

Child, Grandchild, etc

First Youth's Gender *

Female

Male

First Youth's Age *

First Youth's Grade (This Upcoming Year) *

First Youth's T-Shirt Size *

First Youth's Medical History

I certify that the above named youth is in good health and able to participate in all activities. *

Yes

If no, please specify the limits of participation:

Youth Physician, Name and Number *

Any food allergies? *

Yes (Please list below)

Any food allergies?

Please detail any food allergies that you mentioned above.

Any other allergies? *

Yes (Please list below)

Any other allergies?

Please detail any other allergies that you mentioned above.

Youth is under a doctor's care for: *

Please check all that apply:

Asthma

Epilepsy

Diabetes

None of the above

Required

Does the youth have a current tetanus vaccination? *

Yes

Does the youth have health insurance? *

Yes (Please bring a copy on the first day of camp.)

Does the youth have any special emotional or physical needs? *

Yes (Please list below)

Does the youth have any special emotional or physical needs?

Please list any needs mentioned above.

Please list any current medications (prescription or non-prescription)

Do you have other children to register? *

Clear form

Never submit passwords through Google Forms.

Forms

This content is neither created nor endorsed by Google.