| Camp Jubilee 2007 | |||||||||
| Monday, July 30 - Saturday, August 4 | |||||||||
| Camper's Name (last, first, middle initial) | male ?female? | ||||||||
| Address | City | State | Zip | ||||||
| Father's Name | Parent's Home Phone | Dad's Daytime Phone | Dad's Cell Phone | ||||||
| Mother's Name | Mom's Daytime Phone | Mom's Cell Phone | |||||||
| Name of person to notify in emergency if unable to reach parent | Phone Number | Relationship to camper | |||||||
| Birth date | Grade Next Fall | E-Mail Address | T-SHIRT SIZE (Adult)S ?M ?L ?XL ? | ||||||
| HEALTH RECORD | |||||||||
| Please check all that apply: | |||||||||
| ?--overall good health | ?--current infectious disease | ?--recent injuries | ?--behavioral conditions | ||||||
| ?--chronic/recurring illness | ?--allergies (drug, food, insect) | ?--mental/emotional conditions | ?--health or physical condition that makes participation risky or difficult (e.g. orthopedic problems, back or neck injury, hearing or vision limitations) | ||||||
| Explanation for conditions checked above: | |||||||||
| Are immunizations current??Yes?No | Date of last tetanus booster: | ||||||||
| Physician & Health Insurance Information: (If none, please indicate so) | |||||||||
| Family Physician: | Physician's Phone: | ||||||||
| Health Insurance Co: | Insurance Policy # | ||||||||
| Over-the-counter Medications: | |||||||||
| May we administer over-the-counter medications if needed??YES?NO | |||||||||
| Exceptions: | |||||||||
| Prescription Medications: | |||||||||
| Note:You will have the opportunity to update this when you drop your child off for camp. | |||||||||
| 1)All medications brought by the camper (prescription and over-the-counter) must be given to the camp health administrator when you check in.All medications must be in the original container, be prescribed for the camper and include clear and current directions.It is not necessary to bring most common medications such as Tylenol and cold remedies as these are stocked at camp. | |||||||||
| 2)I understand it is the policy of Camp Jubilee not to release a camper to anyone other than the person designated at the beginning of camp. | |||||||||
| 3)In signing this document, I hereby certify that the above information is correct and give the following permissions: | |||||||||
| *For my child to engage in all prescribed camp activities unless indicated above. | |||||||||
| *For the use of photographs including my son /daughter to be used in camp publicity. | |||||||||
| *For the release of medical records in case of illness or injury. | |||||||||
| *In the event I cannot be reached, I hereby give permission to the physician selected by the Camp Jubilee staff to obtain proper medical diagnosis, hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child as named above. | |||||||||
| Special Note: | |||||||||
| On Saturday, August 4, at 1:00pm we will be offering baptism to those who wish to participate.Family and friends are welcome to attend.If your child so chooses, do they have your permission to be baptized??Yes?No | |||||||||
| Camp Fee: | |||||||||
| *The Cost of this camp is $95. | |||||||||
| *Completed registration and camp fee of $95 is due by JUNE 14 to Diane Leech. | |||||||||
| *Or Mail to:Camp Jubilee, c/o Diane Leech, 9809 - 64th Ave, Allendale, MI 49401 | |||||||||
| Parent/Guardian Signature: | Date: | ||||||||