Church Name
*
Kent Island Methodist Church
Youth Leaders Name
*
Youth Leaders Phone Number
*
Child's First Name
*
Child's Last Name
*
Child's Date of Birth
*
MM
DD
YYYY
Current Weight
*
Known Medical Conditions (For Example, Asthma, Migraines, ADHD)
*
Known Allergies (Drug, Food, or Environmental)
*
Will your child be taking any medications while at camp? If Yes please list medication
*
Who will be in Charge of Medication?
*
If they will be taking no medication please select "Child"
Medical Insurance Carrier
*
Insurance Policy Number
*
Consent
In the event my child becomes ill or injured, I authorize the camp nurse to
render aid and/or administer over the counter medication, i.e., acetaminophen,
ibuprofen, antibiotic ointment. In the event of an EMERGENCY, the counselor or camp
nurse will call the parent/guardian at the contact number listed below. If no one can be
reached, I hereby give my permission to the physician selected by the counselor or camp
nurse to secure proper treatment for my child.
To the fullest extent permitted by law, I release Victory Jam Camp its trustees,
officers, directors, employees, agents and representatives from injury, harm, damage or
death which may occur to my minor child while participating in the activity and agree to
save and hold harmless Victory Jam Camp its trustees, officers, directors, employees,
agents and representatives from any claims arising out of my minor child’s participation
in the activity.
First Name
Last Name
Parent/Guardian Email
*
Parent/Guardian Phone Number
*
