CAMPER REGISTRATION

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					                            CAMPER REGISTRATION

Camper’s Name________________________________________________________

Address ______________________________________________________________

City___________________________ State____ Zip_____

Phone ______-_______-________

Church    __________________________

Age__ M/F____

T-Shirt Size(S – XXXL) _____________

             I grant permission for my son/daughter to attend the
             Penn-Jersey District Youth Camp, August 15th-19th.
               Relation to Camper_____________________
               Signature__________________ Date            / /

                               Water Activities
                   I grant permission for my son/daughter
                    to participate in supervised waterfront
                              and water activities.
                Signature__________________ Date            /   /


                         Registration Deadlines:
                        (Postmarked by these dates)
             Monday, June 20th for the $240 cost
             Monday, July 18th for the $280 cost
Anything postmarked after July 18th will be considered a walk on
                    registration at $320
          ALL PAYMENTS MUST BE RECEIVED BEFORE
                  MONDAY, AUGUST 8TH!

         Please mail registration form and a minimum of $100 deposit to:
                                Pastor Brad Swink
                              1414 Pennsylvania Ave.
                               Bethlehem, PA 18018
           Please make checks payable to: Penn-Jersey District Youth
                                 Medical Release Form

Camper’s Name_______________________________
Parent / Guardian______________________________
Phone(day)_______________(night)_______________
Cell #________________
Do you have medical insurance ? ____yes ____no
Company____________________________________
Group #__________________Policy #_____________
In case of an emergency or injury, the hospital will not treat unless permission has
been granted by phone from the parent or other relative. Please list additional
phone numbers where you or another close relative can be reached day or night.
Name of additional relative(s)
______________________________________________
Relationship____________ Phone_________________
Family Doctor__________________________________
Address / phone_______________________________

Please check all that apply:
__Nose bleeds __Upset Stomach __Bed Wetting
__Convulsions __Rheumatic Fever __Diabetes
Infections:
__Eye         __Ear          __Nose       __Throat
Allergies:
__Asthma __Hay Fever __Insect Stings
__Penicillin __Drug/Food(specify)__________
__Other____________________________________

Dietary restrictions____________________________________
Activity restrictions_____________________________
Date of last Tetanus shot________________________
Medications          that          must                            be                taken
_________________________________________
This is for the following condition(s) ______________________________________
When is the medication to be taken? _____________________________________
Does the medication have side affects? ___________________________________
If yes, what can be done to prevent this? __________________________________


In the event that the child becomes ill or injured I give permission for the necessary
treatment at the nearest medical facility and for transportation to that facility.
Parent/Guardian Signature___________________________________________

				
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