Registration Form 1st & 2nd DayCamp

T-shirt Size (Circle One)   Youth sizes     S   M   L Adult sizes    M   L    XL   XXL   XXXL

                          

Sponsoring Church ____________________________________________________________

Name of Camper  ______________________________________________________________

School Grade Completed____________ Sex (circle one)   M   F  Age______ Birth date _________

Parent or Guardian (If camper is a minor) _________________________Home Phone  ____________

Address______________________________ City_______________ St_____ Zip________

In case of emergency, notify: Name___________________________ Relationship______________

Emergency phone numbers:  Day___________________ Night ___________________

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: _____________________________________________________________________________________

_____________________________________________________________________________________

Insurance Company____________________________ Insurance Policy #__________________

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

 

Signature of Parent or Guardian \ Sponsor________________________________ Date___________

 

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 from your church 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 or 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 Tulsa Metro Baptist Association 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 (1) one original and (2) two copies of each registration form.  You keep 1 copy and bring the original and (1) one copy to registration at Kamp.