Camp In the Community 2019
Day Camp June 17-21 9:00am-3:00pm
Email address *
Child's upcoming Grade *
Child's Name *
Your answer
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Age *
Your answer
Home Church/Denomination
Your answer
T-Shirt Size *
Race/Ethnicity *
Your answer
Registering Parent/Guardian Name (First & Last) *
Your answer
Address (Street, City, State, and Zip Code) *
Your answer
Phone Number *
Your answer
Second Contact Name (First & Last) *
Your answer
Second Contact Number *
Your answer
Second Contact Address (Street, City, State, Zip) *
Your answer
List any physical, emotional, behavioral, or mental health concerns
Your answer
Are all Immunizations required for school up to date? *
Date of last Tetanus Shot *
Your answer
List any food or medication allergies
Your answer
Is camper allergic to bee stings? *
Has camper ever been stung by a bee? *
List any Medications the child will need while at Day Camp
Your answer
Parent/Guardian Authorization
Please Sign name and date after reading it completely
In Signing this authorization, I acknowledge that I have read and agreed to the policies outlined in the Camp in the Community Parent Guide and am aware that the activities associated with this event entailed certain inherent risks including damage to property, personal injury, and even death. I understand that my child will be held accountable for their actions and behaviors at Camp in the Community. In consideration for being permitted to participate in this event, I agree to assume all such risks and hereby release and discharge Holston Conference Camp and Retreat Ministries, Inc., it's affiliated camps, officers, sponsors, trustees, employees, agents, and other aids and/or volunteers from any and all liability for any and all damage, loss, injury, or death of every kind and nature whatsoever which in any way arises out of my participation in this event. I hereby give permission to the camp to provide routine healthcare, administer prescription drugs, and seek emergency medical treatment including ordering x-rays and/or routine tests. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp to hospitalize, secure proper treatment, and to order injection and/or anesthesia and/or surgery for me/or my child as named above. The person herein described has permission to engage in all camp activities except noted. I give permission for me/my child to be transported in a private vehicle if necessary. I give permission for photographs taken of me/my child to be used for camp publicity, printed or electronic. *
Your answer
Submit
Never submit passwords through Google Forms.
This form was created inside of First United Methodist Church. Report Abuse - Terms of Service