KMAK-Individual-Registration-worddoc

 (Click the link above for a printable version)

Registration Form 2012

Kids Mission Adventure Kamp

KMAK I – June 4-7  KMAK II – June 11-14   KMAK III – June 18-21  KMAK IV – June 25-28   KMAK V – July 16-19  KMAK VI – July 23-26

Youth: Medium or Large       Adult T-Shirt sizes (circle one: S       M       L XL       XXL     XXXL)

Name of person attending camp: ______________________________________________________

School Grade Completed_________ Sex: (circle one) M  F    Age________ Birth date________________

Sponsoring Church:  ___________________________________________________________________

Parent or Guardian (of minor ) __________________________________

Home Phone  _______________________

Address__________________________________________________

City___________________ St______ Zip________

In case of emergency notify: _________________________________ Relationship_____________________

Emergency phone numbers: Day___________________ Night________________

Cell __________________

Physician’s Name_____________________ (Imperative if your child has allergies.) Phone________________

List any allergies to medications or any known allergies: ______________________________________________________________

Date of last tetanus immunization________________ List medications presently being taken:

__________________________________________________________________

__________________________________________________________________

Medical Insurance Company__________________________ Insurance Policy #___________________

(This above information is needed in case your child or the sponsor has to be taken to the hospital and the parent/guardian cannot be reached.)

__________________________________ Date________________

Signature of Parent /Guardian/Sponsor

AUTHORIZATION FOR EMERGENCY CARE TO A MINOR

I/we the undersigned, parent(s) or legal guardian of the minor (name)_____________________________ (birthday)________________,

do hereby authorize any X-ray examination, anesthetic, dental, medical, or surgical diagnosis or treatment by any physician or dentist licensed by the State of Oklahoma and hospital service that may be rendered to said minor under the general, specific or special consent of:

______________________________________

(Name of adult sponsor who is temporary custodian of minor)

It is understood that this consent is given in advance of any specific diagnosis or treatment being required,   but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise his/their best judgment as to the requirements of such diagnosis of medical or dental or surgical treatment.

Date________________ Parent /Legal Guardian____________________________________________

AUTHORIZATION FOR MEDICAL INFORMATION RELEASE

I hereby authorize the hospital to release the following information contained in its hospital records to the representative of the Tulakogee Conference Center concerning diagnosis, prognosis for

_____________________________________________________ Date of birth ____________________

Name of Camper/Sponsor

This information will be used for insurance billing.  ________________________________ Date _______

Signature of Parent or Guardian/Sponsor

Please make sure you have one (1) ORIGINAL and  one (1) copy of each registration form.

ORIGINAL (1) copy to registration at Kamp.   CHURCH keeps one (1) copy

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