LRCC Camper

REGISTRATION FORM

(Please Print)

Today’s date:

Camper INFORMATION

Campers last name:

First:

Middle:

Grade Entering in 09

Camp (circle one)

Sr High / Jr High / Jr /Prospect /TeePee

Email Address;

Birth date:

Age:

Sex:

/ /

M

F

Street address:

Home phone no.:

P.O. Box:

City:

State:

ZIP Code:

Father’s/Guardian Name;

Phone Number;

Mother’s/Guardian Name;

Phone Number;

Camper’s Home Church ;

City;

Phone;

Health Record The following information must be completely filled out by a parent/legal guardian.
Check for up to date Vaccinations
Diptheria-Tetanus-Pertussis Series (DPT)		Hepatitis B Series		Chicken Pox
Measles- Mumps-Rubella (MMR)
Date of last Tetanus Booster / /
Please note if Camper has any of the following;
Convulsive Disorders	Chronic/Recurring Illness		ADD/ADHD
Frequent Ear Infections	Recent Illness or injury		Contagious Disease
Special Conditions to watch for;
Overall Good Health to participate in Camp Activities. Y/N
Recent Conditions that may restrict this Camper from certain Camp activities;
Optional; any recent life changes (death in the family, divorce, move, etc)

Allergies; Please list any food, medication, insect, etc. allergies and describe reaction and management of reaction.
Allergy;		Reaction/Management;
Allergy;		Reaction/Management;
RX; all medications (prescription/nonprescription) must be in original container and turned in upon campers arrival.
Name of medication	Dosage		Reason for taking;
Name of medication	Dosage		Reason for taking;
Camper’s Physician;	Physician’s Phone #:
Circle Yes No “My child may be given over-the-counter medication as deemed necessary by the camp nurse for comfort measures” (Aspirin will not be given)

INSURANCE INFORMATION

Insurance Company

Person responsible for bill:

Address (if different):

Home phone no.:

Insured’s Dob Not campers

\ \

Group no.:

Policy no.:

Camper’s relationship to subscriber:

()Self

() Spouse

() Child

() Other

IN CASE OF EMERGENCY

Parent/Guardian Name;

Home phone no.:

Work phone no.:

Name of local friend or relative (not living at same address):

Home phone no.:

Work phone no.:

In case of emergency & permission to participate:

“To the best of my knowledge my child is physically and emotionally able to take part in the camp program. In the event of a medical emergency, I give permission for a heath professional to do what is necessary for the health of my child. I have reviewed this form and certify that all appropriate medical information is included.

I recognize that this is a Christian Camp, that the Bible is studied, and that camper conduct will be expected that is consistent with Christian values. I give my permission for the use of photographs/videos including my child to be used in possible future camp publicity.”

Patient/Guardian signature

Date;

Please remember that early registration is May 25^th. If you want the early registration discount, Tim McConkey must receive your registration form and money by May 25^th! All forms and money must be turned into Tim one week prior to the start of camp. Campers; give this form and your money to your church office. Churches; send forms and money to; Tim McConkey c/o First Christian Church 103 12^th Ave. S. Lewistown, MT 59457