Kid Form

Kid's Camp Registration Form

Please complete all 4 Steps of the Registration Form.

Parent/Guardian signature required in the signature box on Step 4.

PARENTS: Please fill out information for YOUR STUDENT CAMPER (not yourself)

CAMPER First Name

CAMPER Last Name

Street Address

City

State

Zip Code

Phone Number

Date of Birth

Grade (going into)

Gender

T-shirt Size

Emergency Contact

Relationship to Camper

Phone #1

Phone #2

Check any medical conditions that apply to this camper

Are there any activities this camper is prohibited from doing?

Has this camper been hospitalized in the last year?

Please list any medications taken regularly

Please list any allergies, medical or otherwise

Please list any additional medical concerns, behavioral concerns or any other information you believe we should know in case of an emergency

Primary Physician

Physician Phone Number

If this camper has insurance please list the information found on their insurance card.

I hereby agree that the above camper may participate in all camp activities including travel off the property. Also, I give permission for New Site Church and Camp Siloam to use images and recordings of this child without further compensation. I realize that in the evet of an illness or injury while at camp or while participating in its activities, medical treatment may be required. I give permission for the medical personnel selected by the camp director to order any medical procedures, including x-rays, routine tests, treatments, hospitalization and transportation. Furthermore, I agree to bear the cost of all such treatment. I also agree to hokld harmless Camp Siloam, its staff, and board of directors from all liabilities, claims, demands, and causes of action whatsoever which may arise due to the participation of this child in said activities.

Name Printed Above

Date

NONE
ADD/ADHD
Asperger Syndrome
Asthma
Autism
Previous Back or Neck Injury
Bladder/Kidney Issues
Blind/Legally Blind
Blood Disorders
Cancer
Cardiac Issues/Hypertension
Celiac Disease
Diabetes
Down Syndrome
Hard of HEaring/Deaf
Hypoglycemia
Immune Disorders
Knee Problems
Migraines
Night Terrors
Physical Disability
Seizure Disorder
Tourette Syndrome
Environmental Allergies
Food Allergies
Insect Bite/Sting Allergies