LaVerne Griffin Youth Recreation Camp

Camper Registration & Health Form

 

Camper’s Name: _____________________________ Birthday: ________________ Sex: _______

Camp Session Attending: _______________________________________ Age: _____________

Parent/ Guardian: _______________________ Phone: _______________ Email: ___________

Work Phone: ___________________________ Cell: ___________________________________

Mailing Address: ________________________ City: ____________ State: ____ Zip: _________

 

Alternate Emergency contacts:

Name: ______________________ Relation: ______________ Phone: ______________

Name: ______________________ Relation: ______________ Phone: ______________

 

Insurance information:

Policy Holder: _____________________________ Policy #: _______________________

Name of Carrier: ______________________________ Group ID #: _________________

Address of Carrier: __________________ City: __________ State: ______ Zip: ______

Family Physician: _____________________________ Phone: _____________________

 

Immunization History (Give Dates)                               Allergies or Reactions DTP Series: ________ Measles: ______                                     List and describe reactions: Last TB: __________ Last MMR: _____                 ___________________________________ Last Tetanus: ______                                                ___________________________________ Recommendations & Restrictions Describe any MEDICINE (specify Name/use), diet or activity the camp nurse or director should be aware of: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Description of Current Health Conditions requiring medication and/or treatment:           My child may be given Tylenol, Advil, Cough Syrup, Anti Diarrhea Medication, Tums, Benedryl, Epinephrin, or their generic equivalent unless otherwise noted below.       Yes___ No___

Parent’s Authorization (This box must be completed for Camp attendance) I hereby certify that this Health History is correct to the best of my knowledge.   I understand the possible risk and dangers involved in sports and other traditional camp activities and do give my permission for the above named camper to engage in all camp activities, except noted by myself or my family physician.  I/We do hereby release LGYRC, its employees, agents, and camp staff from all claims, demands, actions, or causes of action for any sort of injuries sustained during the period covered by this release whether such injury occurs on or off camp property.   I have instructed my child to obey the rules of LaVerne Griffin Youth Recreation Camp.   I hereby give permission for medical treatment to be initiated as required for his/her welfare.     I hereby give LaVerne Griffin Youth Recreation Camp permission to use photo images of the above listed participant for the purpose of promoting the camp’s programs in publications and on the Web.  I agree that the images become the exclusive property of LGYRC and wave the rights thereto.  For privacy and protection of your child/ward, his or her name will not be used on the Web.   Signature of Parent/Guardian: ____________________________ Date: ________________________   Printed Name of Parent/Guardian: ______________________________________________________   Church: ________________________________ Church Chaperone: _________________________   PLEASE NOTE:  Any medications that need to come with your child must be in the original prescription bottles with detailed instructions from your doctor.  The camp’s insurance covers each camper as secondary insurance.  Your family insurance would apply first for any injuries or medical needs.

 

 

Souls Saved... Lives Changed

LaVerne Griffin Youth Recreation Camp

 

 

 

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