FSM Student Life Beach Camp
Event Timing: July 15-21, 2019
Event Location: Daytona Beach // Orlando
Email address *
Chaperone First & Last Name *
Your answer
Address *
Your answer
Cell Phone Number *
Your answer
Have you chaperoned FSM Camp in the past? *
I am interested in... *
T-Shirt Size *
Dietary Restrictions *
Physical Restrictions
Your answer
List All Medications
Your answer
The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted. I hereby give permission to medical personnel selected by Pastor Brian Dawson and/or camp staff to order X-rays, routine tests, and treatment for the above chaperone. In the event of an emergency, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release Temple Baptist Church, its employees or agents from liability associated with participation in this church activity. I understand that if I do not have medical insurance, I will be responsible for any medical expenses in the event of a sickness and/or injury. I understand that there are risks involved in participating in recreational activities and other activities related to participation in youth functions. *
I understand that chaperone spots are not guaranteed and are ultimately determined by Pastor Brian based on student ratios and need. *
A copy of your responses will be emailed to the address you provided.
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