Kidz Kamp Registration 2018
Church you are attending with:
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Student Information
Are you a Leader or Student? *
First Name *
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Last Name *
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Date of Birth *
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Address *
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City *
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State *
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Zip *
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Shirt Size: *
Parent/Guardian Information
Mother/Legal Guardian: *
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Mother/Legal Guardian's Cell Number: *
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Mother/Legal Guardian's email:
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Father:
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Father's Cell:
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Father's Email:
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If parent cannot be reached in the event of an Emergency notify: *
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Phone Number for Emergency Contact: *
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Medical/Insurance Information Student/Sponsor:
Insurance Company: *
Your answer
Policy Number: *
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Group Number: *
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Doctor's Name
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Doctor's Phone Number:
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Student Restrictions or Allergies:
Is your child restricted from swimming for any reason? *
If yes, please explain:
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Date of child's last Tetanus shot:
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Has your child ever had a severe reaction to a bee/hornet sting or insect bite? *
If yes, please explain:
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Does your child have any food allergies *
If yes, please explain:
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Does your child have any issues with bedwetting?
If yes, please explain:
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Does your child have?
If yes, please explain:
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Which of these childhood illnesses has your child had?
List all Medication your child is currently taking (including medicines such as prescribed drugs, over-the-counter drugs, and inhalers):
List name of medicine, strength, and frequency that they take it:
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If your child has to take prescription medication please list the Preferred Pharmacy:
*If your child is taking any prescription drugs please include a signed note from your doctor when they come to camp.
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Preferred Pharmacy Phone Number:
If applicable.
Your answer
*
I give my authority and consent to the Shenandoah District's sponsors/leadership to seek a doctor or qualified person to provide emergency medical treatment to the above named student in the event he/she is ill or injured while participating at Shenandoah Kids Kamp. I, undersigned parent/ guardian of the above mentioned child who is a minor, do realize, acquit, discharge and covenant to hold harmless its sponsors and representatives from any and all actions, cases of actions, damages, and/or liabilities arising from the medical treatment of any sickness or injuries from and accident incurred by my said child during Kids Kamp.
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I give my authority and consent to the Wesleyan Shenandoah District sponsors/leadership to take pictures of my child while at The Shenandoah Wesleyan Kidz Kamp from June 17th through June 22nd of the year 2018. I give permission for the pictures to be used for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content.
Signature of Parent/Guardian: *
Your answer
Date: *
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Please Note:
Your child is NOT officially registered until the $100.00 nonrefundable deposit has been paid to the Shenandoah Wesleyan District office. Either by mail or through the website.
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