LaVerne Griffin Youth Camp Registration & Health Form
A form will need to be filled out for each camper. Siblings CANNOT be combined on one form. Thank you for understanding.
Email address *
Camper's Name (First and Last): *
Your answer
Birthday of Camper (Month/Day/Year): *
Your answer
Sex: *
Camp Attending: *
Parent/Guardian Name: *
Your answer
Parent/Guardian Phone (home, cell, work): *
Your answer
Parent/Guardian Address: *
Your answer
Two Emergency Contacts (Name, Relationship to Camper, and Phone Number) *
Your answer
Insurance Information for your camper is required. Please list the Carrier, policy holder name, ID #, Group #, Address of Insurance, and Phone of insurance. *
Your answer
Primary Care Doctor and Phone Number: *
Your answer
Immunization History (Give Dates): *
Your answer
Medication, diet, or any medical conditions the Camp Nurse should be aware of? *
Your answer
Please list any allergies and reactions (If none, please type NONE): *
Your answer
Essential Medical Information: All medications must be in the original prescription bottles with detailed instructions from a doctor. For the safety of everyone in camp and to comply with regulations, all medication will be stored in our nurse's office. The following over the counter medications are kept in the nurse's office & are provided to campers by our Camp Nurse. These would include: Acetaminophen, Ibuprofen, Tums, Mylanta, and Benadryl. LaVerne Griffin Youth Camp does not provide specialized diets. The Camp Nurse is available the day of check-in for any questions or concerns. *
Parent's Authorization (ALL boxes must be selected to continue with camp registration) : *
Required
I give LaVerne Griffin Youth Camp permission to use photographic images or videos of the above participant for the purpose of promoting the camp's programs in publications, social media, and on the web. I agree that the images become exclusive property of LaVerne Griffin Youth Camp and wave the rights. For privacy and protection of your child/ward, his or her name will not be used.
Printed Name of Parent/Guardian(***AFTER submitting this form, a link will appear. Please click this link to provide us with your signature***): *
Your answer
Date: *
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Will your camper be associated with a Church/Church Chaperone? If yes, what Church/Church Chaperone?
Your answer
A $25 non-refundable deposit is due at registration in order to reserve your campers spot. You can also pay the entire amount via check or PayPal. If you'd like to pay via PayPal, click the link below ***(Note: this will bring up a separate window to send payment. You will still need to complete this form and click "SUBMIT" at the bottom.)*** *
A copy of your responses will be emailed to the address you provided.
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