Merge Camp
Registration Packet for Campers
Email address *
Last Name of Camper *
Your answer
First Name of Camper *
Your answer
T-Shirt Size *
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Gender *
Grade going into fall of 2019 *
Primary Parent / Guardian Name *
Your answer
Primary Phone Number *
Your answer
Secondary Phone Number *
Your answer
Emergency Contact *
Your answer
Primary Phone Number *
Your answer
Secondary Phone Number *
Your answer
Name of Physician *
Your answer
Phone Number *
Your answer
Medical / Insurance Carrier *
Your answer
Policy / Group Number *
Your answer
Date of Last Examination *
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Name of school where CURRENT records are kept: *
Your answer
Chronic / Recurring Conditions... Check all that apply: *
Required
If other, please list:
Your answer
Food Allergies: *
Your answer
Medicine Allergies: *
Your answer
Restricted Activities... Check all that apply: *
Required
If other, please list:
Your answer
Will you be taking medication at camp? All medication must be in the original container and administered by the camp nurse. *
Check all the over counter medicine approved to be administered AS NEEDED by the camp nurse: *
Required
List Exceptions
Your answer
Which fundraising events will your child be participating in: *
Required
Type name for consent... I hereby certify that I as a leader or I as a parent / guardian give my consent of participation of Merge Camp 2019. I agree and to hereby waive and release all claims against Merge Community Church and any sponsor or other person engaged in Merge Camp and agree to hold them harmless from any and all liability. I hereby give the authority to the designated personnel of Merge Community Church to consent to medical treatment in the event medical attention becomes necessary. This authorization includes the authority to sign releases on my behalf for medical services. The foregoing to whom I give such authority is a religious institution and I will be financially responsible for any cost incurred for medical treatment. *
Your answer
Date: *
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Time: *
Time
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