SR Camp CAMPER

Name

Gender

Male Female

Age

This address will receive a confirmation email

Home Phone

Mobile Phone

Date of Birth

Camper Will Stay in a:

Dorm RV/RV form must be on file

Each camper is allowed to name ONE other camper they would like to stay in the dorm with. PLEASE NOTE that every effort is made to place all campers from the same church together (separated between the boys and girls dorm). Please list name below.

T-Shirt Size (included in camp tuition)

Address

Name of Pastor (Must be UPCI Licensed)

Official Church Name

Location of Church (city/state)

Mother's Name

Mother's Primary Phone Number

Father's Name

Father's Primary Phone Number

Have read and understand the Camp Policy and Dress/Conduct Code and have advised Camper of these rules and their obligation to abide by them.

Yes No

Understand that I will be notified in case of a medical emergency involving the Camper. If I cannot be reached, I authorize the calling of a doctor and/or the providing of necessary medical services. I authorize the Camp Nurse and Executive Staff to make emergency medical decisions on behalf of Camper as required by law. I understand the Texas District UPC will not be responsible for medical expenses incurred solely on the basis of this authorization. I agree to notify the Camp Office in the event of any health changes that would restrict Camper’s participation in any/all Camp activities. I understand that adult supervisors reserve the right to withhold Camper from any activity they feel is outside the physical capabilities of Camper. I also understand that my personal insurance (if applicable) is primary coverage, and the Camp Insurance is secondary.

Yes No

Understand Camper will not be admitted to Camp if they have lice or nits; and if lice or nits are found, it is my responsibility to pick up Camper.

Yes No

Does your camper require prescription and/or over the counter medication?

Yes No

NOTE: All medication must be turned in to the Nurses’ Station in original containers with doctor’s instructions. Use separate sheet if necessary.

If yes. please explain:

I give permission for Camper to be given OTC medication provided by Camp Nurse for minor sickness (Tylenol, Motrin, Pepto Bismol, etc.) List any exclusions

Yes No

Please list any exclusions:

Camper’s immunizations are up to date as required by the Texas Public School System?

Yes No

Camper’s immunizations are not up to date as required by the public school system, or I have chosen not to immunize my camper.

Yes No

Certify the Camper is physically fit and adequately prepared to participate in any/all activities of Camp unless otherwise noted in Camper’s medical information.

Yes No

Primary Guardian's Name

Primary Guardian's Telephone Number

Primary Guardian's Alternate Number

Secondary Guardian/Emergency Contact Name

Secondary Guardian/Emergency Contact Number

Family Physician Name and Phone Number:

Dentist/ Orthodontist Name and Phone Number:

Insurance Carrier and Phone Number:

Insurance Group Number:

Camper has been diagnosed with and/or treated for head lice in June

Yes No

Camper has sleep issues that necessitate a bottom bunk.

Yes No

Camper’s immunizations are up-to-date as required by the public school system?

Yes No

Camper has ever required any psychiatric treatment, counseling or hospitalization?

Yes No

If yes, please explain:

Camper has ANY injury/sickness preventing him/her from participating in Camp activities or which Camp Staff should be made aware?

Yes No

If yes, please explain:

Camper has ANY allergies or food modifications?

Yes No

If yes, please explain:

Camper will stay in:

I give permission for camper to check out of camp Friday, June 21 with the following

Primary Guardian/Secondary Guardian ONLY Church Group (Church listed on Application) Other (if you choose other list below)

Give permission for Camper to check out of Camp on the date of with the following person(s)/group

Complimentary registration is reserved for Real McCoys, children of Youth Committee members, and others approved only by Bro. Williams

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

SR Camp CAMPER

Description

Please Fix the Following