CAMP REGISTRATION | Impact YTH

CAMPER INFORMATION

Full Name (First, Middle, Last)

What kind of camper are you?

Gender

Age

Birthday

Month

Day

Year

T-Shirt size

Parent/Guardian (if not yourself)

Phone

Address

Home Church

If your home church is not listed above, please list church name and Lead Pastor:

EMERGENCY CONTACT INFORMATION

1. Name & Relation (first point of contact)

Phone Number

2. Name & Relation (second point of contact)

Phone Number

MEDICAL INFORMATION

Medical Forms:

https://46cda539-03c7-4953-a84c-694f1198b843.filesusr.com/ugd/cdeba1_8aafe0edcf9f4e10a2111b3048df799e.pdf

PLEASE BRING THE ORIGINAL (SIGNED & NOTARIZED) MEDICAL FORMS WITH YOU TO CAMP

File upload

ARE YOU OR YOUR CHILD BRINGING MEDICATION TO CAMP?

NON-PRESCRIPTION MEDICATIONS ARE STOCKED AND KEPT WITH THE CAMP NURSE. THESE OVER-THE-COUNTER MEDICATIONS ARE USED ON AN AS NEEDED BASIS AND WITH THE NURSE'S BEST MEDICAL JUDGEMENT, TO MANAGE/TREAT ILLNESS AND/OR INJURY.

THE FOLLOWING IS INVENTORY OF ALL OVER THE COUNTER MEDICATIONS AVAILABLE AT THE CAMP NURSE’S STATION:

ACETAMINOPHEN (TYLENOL), CALAMINE LOTION, IBUPROFEN (ADVIL, MOTRIN), BISMUTH SUBSALICYLATE (PEPTO-BISMOL), CLARITIN, ZYRTEC AND OR ALLEGRA, HYDROCORTISONE 1% CREAM, ROBITUSSIN, TOPICAL ANTIBIOTIC CREAM (NEOSPORIN), DIPHENHYDRAMINE (BENADRYL), ALOE VERA, GENERIC COUGH DROPS, CHLORASEPTIC (SORE THROAT SPRAY)

By clicking this box you're giving the camp nurse permission to treat you, or your child as needed with the medications listed above.

AUTHORIZATION & SIGNATURES

By signing, the parent/legal guardian agrees to bear all responsibility in cost of picking up camper and no refund of any remaining time will be granted.

I, hereby, waive any and all claims against the PCG Central District, The Pentecostal Church of God, or any of its District Board, or its representatives, because of injury, or other damage that may be incurred to me or my personal property in connection with, or incident to, the Pentecostal Church of God. I understand that accidental medical insurance (Secondary) is provided in the camp cost, but that any personal medical insurance coverage information provided on this form is Primary. Rules of acceptance and participation in the program are the same for everyone without regard to race, color, national origin, age, sex or handicap. I also give Central District the right to use my picture, voice, and/or any testimony in any form of promotional or advertising materials. My enclosed signature signifies my approval of all limitations listed above.

Full Name (First, Middle, Last) of signer

Signature

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