Beulahland Christian Camp Registration
Week Attending *
Grade Completed in 2018 *
Full Name *
First and Last
Your answer
Nickname
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zipcode *
Your answer
Age *
Your answer
Birth Date *
MM
/
DD
/
YYYY
Sex *
T-shirt Size *
First time attending camp? *
Father's Full Name
(or male guardian)
Your answer
Parent Email *
Your answer
Father's Cell Number
Your answer
Father's Work Number
Your answer
Father's Home Number
Your answer
Mother's Full Name
(or female guardian)
Your answer
Mother's Cell Number
Your answer
Mother's Work Number
Your answer
Mother's Home Number
Your answer
Primary Contact for Emergencies *
Provide Contact information if contact information is not listed above
Your answer
Does the child have health insurance? *
Company
Your answer
Policy Number
Your answer
Family Physician
Your answer
Family Physician Phone Number
Your answer
Immunizations - Month & Year
N/A if not applicable
D.P.T. Series *
Your answer
Tetanus *
Your answer
Mumps *
Your answer
Measles *
Your answer
Rubella *
Your answer
Other (specify) *
Your answer
Allergies
Environmental *
or none
Your answer
Poison Ivy/Oak *
or none
Your answer
Insect Stings *
or none
Your answer
Foods (Please specify) *
or none
Your answer
Other
Your answer
Is the Camper bringing medications to camp? *
If Yes, what medication?
Your answer
This health history is correct to my knowledge, and the person described herein, has permission to engage in all prescribed camp activities, except those listed by me here: *
Signature of Parent/ Guardian (If camper is a foster child, the case worker must sign)
Your answer
In the event I cannot be reached in an Emergency, I hereby give permission to the physician, selected by the Camp Director/ Manager, to hospitalize, secure proper treatment for, and to offer injection, surgery or anesthesia for the person named above. *
Signature of Parent/ Guardian (If camper is a foster child, the case worker must sign)
Your answer
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