FSM Student Life Beach Camp
Event Timing: July 9-15, 2018
Event Location: Daytona Beach // Orlando
Student First & Last Name *
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Student Address *
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Student Cell Phone Number *
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Grade Entering *
Student T-Shirt Size (Adult) *
Roommate Request
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Dietary Restrictions *
Physical Restrictions
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List All Medications
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Parent/Guardian First & Last Name *
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Parent/Guardian Cell Phone Number *
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Parent/Guardian Email *
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Parent/Guardian First & Last Name
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Parent/Guardian Cell Phone Number
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Parent/Guardian Email
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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 student. 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, as the parent or guardian, 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 my student's spot is not reserved until I have paid the $150 deposit *
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