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Lamar Lighthouse Camp

Registration Form

First Name
Middle Name
Last Name
Preferred Name or Nick Name
Male
Female
Email Address
Address
Telephone Number
Birthdate
Age on 08/03/2006
Grade entering in the fall
Name of church
Pastor
Pastor's Phone Number
Parent/Guardian (1)
Address
Home Phone
Work Phone
Cell Phone
Parent/Guardian (2)
Address
Home Phone
Work Phone
Cell Phone
Emergency Contact
Phone Number
Relation to Camper
Is this camper in general good health to participate in all camp activities? Yes
No
If no, please submit a statement indicating limitations.
Please check any ongoing health conditions and explain below or attach a note
ADHD
Allergies
Anxiety
Asthma
Bed Wetting
Bleeding/Clotting Disorder
Convulsions/ Epilepsy
Depression/Emotional Disorder
Diabetes
Ear/Hearing Problems
Eye/Vision Problems
Fainting
Heart Defect/Disease
Homesickness
Hypertension
Insect Stings
Learning Disability
Sleep Disorder/Walking
Other
Please indicate the date of your child's last tetanus booster
Please indicate the most recent physical examination date
Name of primary care physician
Office
Phone Number
Insurance Company
Policy Number
  

Parent Release

 

I certify that I am the parent or guardian of the above named child.  In case of medical emergency, I understand that every effort will be made to contact the parent or guardian of the camper named above.  In the event that I cannot be reached, I hereby give my permission to the physician selected by the camp leaders to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child as named herein.  I understand that Camp Lamar does not carry medical or accidental insurance for the camper participants, and hereby certify that my child, named above, is covered by a personal insurance policy or is included in a policy which is in force.  Further, I hereby authorize routine medical dispensary care for the above named camper and authorize treatment not considered routine to be referred to local physicians and medical facilities at my expense.  In signing this registration, I hereby certify that all information is correct and I give my permission for the use of photographs and video footage including my child in camp publicity, for my child to be transported in camp operated vehicles for approved out-of-camp activities and for purposes of medical transport, and for the release of medical records in case of illness.

 

My Name____________________________________________________________     Date______________

 

Signature_________________________________________________________________________________

 

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