Medical Release
|
|
|
|
Camp Bethany Registration Form
Name: _________________________________________________________________________________________ Address: _________________________________________________ Email Address: _________________________ City, State & Zip: ________________________________________________________________________________ Home Phone: ___________________ Parent’s Work Phone: ____________________Cell Phone: ________________ Birth Date: _____________________________________ Age: _________ School Grade Completed: _____________ Circle Gender: Male Female Circle Qualification: Student Adult Leader Youth Pastor Shirt Size: ____________ Church Member? Y N Church Name__________________________________________
Camps: (check one) Grades Cost Dates Register By: Registration Fee ___ Kidz Mission Camp 3-6 $ 120.00 June 22-25 May 23 $25 ___Preteen Camp I 4-6 $ 140.00 June 29-July 3 June 1 $25 ___Preteen Camp II 4-6 $ 140. 00 July 6-10 June 1 $25 ___Camp Fuego I 6-12 $ 150.00 July 13-17 June 15 $45 ___Camp Fuego II 6-12 $ 150.00 July 20-24 June 15 $45 Permission for Treatment and Photo/Video Notice In the event that ____________________ becomes ill or sustains an injury while participating in or traveling to or from an authorized and chaperoned youth event at Camp Bethany in Bethany, Louisiana. I, the undersigned, give my permission to those in charge to take whatever steps are necessary to stop any bleeding and/or administer first aid. I also consent to X-Ray examinations, Anesthetic, Medical, Dental, or Surgical diagnosis and treatment, including invasive procedures and hospital care as well as the administration of drugs or medicine to be rendered to my son, daughter or child under my legal watch care, under the general or specialized supervision and upon the advice of a duly licensed physician and/or surgeon. I understand that this consent will apply to all emergency situations present and future and will remain in effect until written revocation is received by certified United States Mail. I also agree that Camp Bethany, the Northwest Louisiana Baptist Association, its staff and/or volunteers will not be held responsible for any physical or emotional injuries received while participating in events and travel associated with Camp Bethany and the Northwest Louisiana Baptist Association. I assume all responsibility for any medical and emergency expenses associated with any accident , injury, or other incapacity, regardless of whether I have authorized such expenses. Also, I understand that as a participant, my child may be photographed or video taped during normal activities and these photos/videos may be used in promotional materials. Signature of Participant ________________________________________ Date ____________________ Signature of Parent or Guardian __________________________________Date ____________________
Insurance Information Insurance Name _________________________________ Insurance Policy Number_________________ Coverage Verification Number_____________________ Subscriber Name _______________________ Place of Employment: ____________________________ Work Phone: ___________________________
Medical Information Generally my health is (check one) __ excellent __ good __fair ___ poor If fair or poor, please explain your condition: ______________________________________________ List any medical difficulties for which you are currently being treated____________________________ List any previous operations or serious illnesses: ____________________________________________ List any medications you are currently taking: _______________________________________________ NOTE: All medications must be in the original prescription bottle with the name of the camper on it and the dosage instructions. Otherwise, we are not allowed to dispense medication. List any Special Diet: ________________________________________________________________ Date of Last Tetanus Immunization: ____________ Family Doctor_________________________________ Phone Number_________________________ Registration: The registration fee is $25.00 per camper. Balance is due on arrival at camp. All counselors pay regular price. Make checks payable to Camp Bethany. Refunds will be made up to one week before camp. Church leaders should collect registration forms and fees and sent to Camp Bethany PO Box 250 Bethany, LA 71007 For Camp use only Reg. Fee $______ date ____ Balance $________ date____ Total $_______________ |
