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WINTER CAMP REGISTRATION FORM
Name
Birth Date
Age
+
-
Weekend(s) Attending
Primary Ages 6-9 January 22-23
Junior Ages 9-12 February 5-6
Teen Ages 13-18 February 19-20
Male
Female
Address
City
State
Zip Code
Parent/Guardian
Primary Phone
Secondary Phone
Email Address
Home Church
City
State
Cabin-Mate
Michigan state regulations require the name of the person(s) to whom we may release your child. Please release my child to:
1.)
2.)
In case of emergency, the camper’s personal health insurance will be used before Camp Selah’s coverage.
Insurance Company
Policy Number
Phone
HEALTH INFORMATION
Date of Last Tetanus Shot
List All Allergies
*FOOD ALLERGIES Please see our Important Info for Parents Page!
Health History (Check all that apply)
Heart Trouble
Seizures
Asthma
Headaches-mild
Diabetes
Migraines
Sleepwalking
Bedwetting
Emotional or Behavioral Disorders
Other health and/or behavioral considerations
Current Medications
All medications brought to camp must be in their ORIGINAL CONTAINERS with dosage/frequency labeled accordingly.
PARENTAL AGREEMENT
“I hereby certify that the above information is correct, and give permission for the use of photographs or videos including my child to be used in camp publicity, and for the release of medical records in case of illness or injury. In the event that my child's emergency contact cannot be reached, I hereby give permission to the physician selected by Camp Selah to give emergency medical or surgical treatment and routine non-surgical medical care to my child.” PARENT/GUARDIAN ELECTRONIC SIGNATURE
Date
The
Privacy Policy
applies.
Note:
Please fill out the fields marked with an asterisk.
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