Registration and Medical Release
Camp Session # ___
__________________________ __________ _________________________
Participant's name Age Date of camp
(Please print)
______________________________________ _________________________
Guardian, if Participant is under 18 years of age E-mail address
______________________________________ __________________________
Street Address City, State, Zip
______________________________________ ________________________
Phone Number Alternate Phone Number
______________________________________
Cell phone
In case of medical emergency, it is my understanding that first aid will be administered, if deemed
necessary. Should the situation prove to be more serious and first aid is not sufficient treatment,
it is my understanding that my child or I will be transported to the nearest emergency facility, or if
possible, the medical facility listed below, and I authorize this facility to provide medical or
surgical procedures necessary to preserve the life or well-being of the above named participant.
________________________________________________________________________
Preferred Hospital or Medical Facility
___________________________________ __________________________
Person to contact in case of emergency Phone number
_______________________________________________________________________
Any known allergies or medical conditions of which the hospital should be aware
_______________________________________________________________________
Medications your child currently taking
___________________________________ _____________________
Parent or guardian signature Date