CrossTimbers Registration 2019 - 7/24-7/27
Email address *
$25 Deposit or $75 Total Fee To Complete Registration
Campers Information
Child's First Name *
Your answer
Child's Last Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Gender *
Age *
Your answer
Grade Completed *
T-Shirt Size *
Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Parent/Guardian & Emergency #'s
In Emergency Notify *
Your answer
Relationship
Your answer
Call This Phone # *
Your answer
Work Phone #
Your answer
Secondary Emergency Contact *
Your answer
Secondary Emergency Contact Phone # *
Your answer
Medical Information
Any Known Allergies? (Food, Medications, etc.) *
If yes, please specify
Your answer
Does camper take regular medications?
If yes, what medications and for what reasons
Your answer
Please list any other medical conditions that would be helpful.
Your answer
Date of last tetanus immunization *
MM
/
DD
/
YYYY
Please provide insurance information
Insurance Company?
Your answer
Name on Insurance Policy
Your answer
Insurance Company Phone Number
Your answer
Policy Number
Your answer
Mailing Address for Medical Claims ( See back of card)
Street Address
Your answer
City
Your answer
State
Your answer
Zip
Your answer
If your insurance requires notification prior to emergency health care please provide phone number
Your answer
Will parent or guardian of the Camper attend camp during the same period of time as the Camper?
If yes, name of parent/guardian
Your answer
Payment (Online Link in Email Receipt) *
A copy of your responses will be emailed to the address you provided.
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