CAMP MACK REGISTRATION FOR ALL CAMPS AND RETREATS

Last Name
First Name
Address
Telephone #
City
State, Zip
E-mail
Congregation
Choose Camp Desired (if applicable)
Choose Retreat Desired (if applicable)
Indicate Dates:
Request:

FILL OUT BELOW FOR MINOR CAMPERS

Date of Birth:	Month Day Year
Age
Grade Completed By Camp Time
Gender
Parents' Name
Add'l Phone #
Address if different from above
If not available in an emergency, notify:
Phone #
Name of person picking up minor camper:
Phone #

Operations/Serious Injuries

Chronic/Recurring Illness

Hernia
Current Broken Bones

Health Restrictions

Health Restriction
If yes please list
Diet
Activities
Adaptations or limitations to Activities
Emotional or traumatic events in the campers life we should be aware of

Medications

List all Medications taken:
List all medications to be taken at Camp:
Purpose for the medication

In signing this application, I certify that all information is correct and my child/ward is in good health and may participate in camping activities. I give consent for camp officials to act in any emergency in the best interest of the health and welfare of my child/ward. Should it become necessary for him/her to return home during the week because of illness, accident, homesickness, or conduct, I will abide by the camp's decision in this matter and provide transportation. I recognize that certain hazards and dangers are inherent in camp events and programs. I understand, also, that although the camp has taken precautions to provide proper supervision, instruction, training and equipment for each activity, it is impossible for the camp to guarantee absolute safety. I further understand that my child/ward shares responsibility for his/her safety and I have instructed my child/ward in the importance of knowing and abiding by camp rules, regulations, and procedures for the safety of camp participants. Further, I waive any claim that may arise against the camp and/or its employees as a result of participation in the program, except for those that are the result of gross negligence of the camp or its employees. I also give permission for person named to be photographed and or video taped for promotional purposes.
Signature: (Parent or Guardian for minors)
Date:
Is the person on this form covered by family medical/hospital insurance?
Medical Insurance Company:
Insurance #:
Physician:
Physician Phone # (with area code):

Designed by Digital Hill Multimedia Inc.