Fun For Jesus Camp Registration - July 19 & 20,
2008
(One participant per form –
you may copy this form.)
Last Name: ___________________________ First Name: ______________________
Mailing Address:
e-mail Address: ________________________________________ Gender: ___M ___F
Date of Birth: ______/______/_____ Age: ________ Grade (just completed): ________
Parent / Guardian(s): ____________________________________________________
Home Phone : __________________________ Work Phone: ____________________
Emergency Contact (in case above parent/guardian cannot be reached): Relationship: ___________
Name: _________________________________________ Phone: ________________
Payment ($15 per camper): Amount Enclosed: __________ Cash _____ Check _____
(Make checks payable to Hope
United Methodist Parish & mail to:
Mary Miller, 24926 Amarillo
Ave., Linden 50146 )
CAMPER HEALTH HISTORY and AUTHORIZATION
Health Insurance – Is participant covered by health insurance? ___ Yes ___ No
If yes, carrier or policy name: ______________________________________________
Policy number: _______________________ Policy holder: ______________________
Relationship of camper to policy holder: ______________________________________
Mailing address of insurance company: ______________________________________
Allergies – Describe cause, reaction and treatment.
Foods: ________________________________________________________________
Medications: ___________________________________________________________
Poison Ivy /Oak: ________________________________________________________
Insect bites / stings: _____________________________________________________
Other allergies or reactions: _______________________________________________
HEALTH CONDITIONS – Please indicate if participant has any of the following and how it is best managed and/or treated.
___Asthma ___Seizures ___Fainting ___Sleep Walking
___Hearing Impaired ___Vision Impaired ___Back Pain ___Heart Conditions
___Bed Wetting ___Chronic Illness ___Diabetic ___Other
Explain any marked conditions: ____________________________________________
______________________________________________________________________
Immunizations
Current? ___Yes ___No Date of last tetanus shot: ______________
Medications – Please list all that are currently being taken.
Medication:
______________ Dosage: _______
Medication:
______________ Dosage: _______
Medication:
______________ Dosage: _______
Restrictions – Please indicate any physical, mental, or emotional conditions that could / would restrict activity while at camp and please describe the best way to handle the restriction. __________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________
Family Dr: _________________________City _____________ Phone _____________
Hospital: ______________________________________________________________
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
Medical Authorization
The participant is currently taking only
medication listed above. The camper has
no allergies known to me/us except as noted on this form. The health information/history is correct to
the best of my knowledge.
In the event of illness or injury, I/we
authorize the physician and/or hospital to undertake such treatment and perform
such services (including surgical) for the participant as are reasonably
indicated by the circumstances.
Signature of LEGAL Parent / Guardian: ____________________________________
Date: ________________________________
(Do Not Write Below – Staff Use Only)