Microsoft word - 2013 guadalupe christian camp-camper.doc

GUADALUPE CHRISTIAN CAMP
HEALTH INFORMATION FOR CAMP NURSE:
CAMPER REGISTRATION FORM
(PLEASE PRINT)
There will be a Registered Nurse on duty at camp. She/He will need your permission to administer additional medications if necessary to your child. When sending medications with your child, the medications must be in the proper container with labeled instructions by the
Name of Camper:__________________________________________________________ Some of the medications that are available at camp are: Name of Parent/Guardian:___________________________________________________ IBUPROFEN
Address:__________________________________________________________________ PEPTO BISMOL
City/State/Zip:____________________________________________________________ IMMODIUM
EYE DROPS
NEOSPORIN
BENADRYL CREAM
HOME PHONE:_______________________EMERGENCY PHONE_______________ CORTISONE CREAM
COUGH SYRUP
Age of Camper:______________ Date of Birth: Mo._______ Day______ Yr._________ Grade entering this Fall:_______ HOME CHURCH:______________________________ COUGH DROPS
BENADRYL
Minister:_________________________________________________________________ IMMERSED? YES or NO Permission to be Baptized: YES or NO Camper is attending with (church):____________________________________________ Please MARK OUT and INITIAL the ones your child may NOT have.
Has camper attended GCC before: YES or NO if YES-number of years___________ Dates of the camp CAMPER is planning to attend:_______________________________ If none of these are marked, I will know it is OK to administer
medications if needed.

LIABILITY and MEDICAL RELEASE FORM:
Is CAMPER allergic to any foods? YES or NO if yes, please list!! _____________________________________________________________ I certify that _______________________has my approval to participate in When was the last TETANUS SHOT administered?___________________ the camp program. FURTHER, I do release and hereby agree to hold blameless the Major operations or illnesses in the past year? YES or NO named church and Guadalupe Christian Camp and its employees and agents from Describe:______________________________________________ any and every claim arising or which may be asserted by me or by any member of Camper is on the following medication (give directions for use)__________ my family by reason of participation in said activity or other activities associated _____________________________________________________________ Other information:______________________________________________ My child has my permission to participate in any hiking activities that are scheduled by Guadalupe Christian Camp. YES NO __________(initial) I hereby certify that __________________________is in good FURTHER, I do authorize the Minister or Sponsor of this activity, in the physical condition with no organic weakness or other problems that would event I cannot be reached by phone, to give consent to a physician and/or hospital make it unsafe to engage in normal camping activities such as competitive for emergency or surgical treatment for my child in the event of sickness or injury games, running or hiking. My signature for approval is below. requiring emergency treatment while on this trip. It is understood that I will assume I,________________________, give the CAMP NURSE permission to any financial responsibility for any expenses that may be incurred for said administer the above described medications to my child,_______________. You may administer all medications except the ones marked and initialed. FURTHER, I do CERTIFY that my child is covered by adequate medical insurance. My consent and signature is given below. I have read and agree to the
Parent or Guardian:_______________________________ Date:_________ information given in this entire form.
If you have any questions, please contact the CAMP NURSE at

Source: http://raintreechristian.org/~raintree/cms-assets/documents/105765-877181.2013-gcccamper.pdf