Signup- Splash Canyon 2018.docx

Westside Free Will Baptist Church / Splash Canyon (SC)
CAMPER HEALTH/REGISTRATION FORM
Preregistration cutoff date is Sunday, April 30 th . Registering before this date qualifies your spy in
training for a free International Spy Academy T-SHIRT!
Will your camper be staying overnight? (Ages 7-11 yrs) (Circle One) Yes No
Campers Name: DOB: / / Gender: (Circle One) M F
Home Church: Phone: ( )
Address: City: State: Zip:
(If applies to you) CDIB#:
(Please Send Photo Copy)
Home Phone: ( ) Parent/Guardian Name:
Emergency Contact:
Emergency Phone: ( ) Relationship:
HEALTH INFORMATION
Allergies: Circle one: Yes
No
--If yes, please list what you are allergic to:
(use the back of this paper if necessary)
Medicine(s) you are presently taking:
Date of last tetanus shot: Are you current on all your shots: (Circle one) Yes No
Are there any special conditions/health problems that we should be aware of: (Circle one) Yes No
(use the back of this paper if necessary)
If yes, please explain:
Your physician’s name: Office Phone: ( )
HEALTH INSURANCE INFORMATION
Personal Ins. Coverage (Your Insurance) Company Name:
Address: City: State: Zip:
Phone: ( ) Policy Number:
(West Side Free Will Baptist Church/Splash Canyon DOES NOT provide insurance)
PERMISSION TO RECEIVE MEDICAL HELP FOR CAMPER IF NEEDED
I/We ___________________________________, the parent(s)/guardian(s) of the above-named camper,
hereby give consent to provide camper with emergency care, and/or hospitalization for any accident or
illness, which occurs while attending SC Church Camp and also give permission to transport camper to
and from localities where such health services are provided. I/We understand that the Westside Free
Will Baptist Church and SC Church Camp are not liable for any medical cost.
Signed: ______________________________ Relationship: _________________Date: ___/___/_____
STATEMENT
I/We have read or have had read to us the SC Church Camp Code of Conduct, rules, and regulations.
We agree that the above-named camper will follow these rules while at SC Church Camp. We
understand that the Westside Free Will Baptist Church and Church staff/volunteers are not liable for
any accidents that happen at SC Church Camp
Parent/Guardian Signature:
Date:
Camper Signature:
Date:
Revised 2018

ADDITIONAL MEDICAL INFO/INSTRUCTIONS.
FOR: