Youth Camp Registration

Please fill out this form and click submit.

Name:

Shirt Size 3XL 2XL XL L M S

Date of Birth:

Gender:

Grade:

School:

Optional

Street Address:

Student Cell Phone:

Student Email:

This address will receive a confirmation email

Father/Guardian:

Optional

Father's Work Phone:

Optional

Father's Cell Phone:

Optional

Mother/Guardian:

Optional

Mother's Work Phone:

Optional

Mother's Cell Phone:

Optional

Student Lives With:

Optional

Both Parents Mother Father Grandparents Other (Please Inform St. Rose Community Church of living situation)

Emergency Contact #1:

Optional

Emergency Contact #1 Relationship:

Optional

Emergency Contact #1 Phone:

Optional

Emergency Contact #2:

Optional

Emergency Contact #2 Relationship:

Optional

Emergency Contact #2 Phone:

Optional

Physician's Name:

Optional

Physician's Phone:

Optional

Hospital Preference:

Optional

Insurance Company:

Optional

Policy #:

Optional

Medical History

Check all categories that apply to your student.

Medical History:

Optional

Asthma Diabetes Epi-Pen Fainting Spells Headaches Hearing Problems Heart Condition Sinus Trouble Seizures Other (Please Inform St. Rose Community Church)

Does your child wear contact lens?

Optional

Yes No

Does your child wear glasses?

Optional

Yes No

Date of last Tetanus shot:

Optional

Special Health Needs:

Optional

Are you under a Physician's care for any illness? (if yes, please explain)

Optional

Allergies

List allergies (food or drug) that your child has:

Medication that may cause allergic reaction:

Optional

Food:

Optional

Treatment:

Optional

Penicillin or other drugs:

Optional

Treatment:

Optional

Insect bite/stings:

Optional

Treatment:

Optional

Poison Sumac, Oak, Ivy:

Optional

Treatment:

Optional

Other:

Optional

Treatment:

Optional

Medication

Include prescription, over-the-counter, and herbal medication.

Medication #1 (Name, Used to treat):

Optional

Medication #2 (Name, Used to treat):

Optional

Medication #3 (Name, Used to treat):

Optional

Release Waivers should be distributed, signed, and returned to the individual church through which you are attending.

Description

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