Send in this form or give it to a staff person at time of pick up for camp or club
Youth's Name(please print)___________________________ Age______
Birthdate_____________ Grade Completed________
Dates attending camp or club activity__________________________
Name of Parent(s) Guardian(s)____________________________________________
Addresss: (Street)__________________ City__________State______ Zip______
Home phone _____ ______________ Work Phone _____ __________________
Insurance Co.______________________ Policy Holder_______________________
Policy Number_________________________________
Emergency Contact Person___________________________ Phone____ _________
Immunization Date: Tetanus Booster___________________
Check any which apply: asthma___ epilepsy___diabetes____heart trouble___
Other_________________________________________________________
Allergies____________________Special medication or diet________________
Serious accidents, injuries or other importat information the camp should have:
______________________________________________________________
My son or daughter has permission to engage in all GEM Camp and Club activities. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp or club director to secure proper treatment or hospitalize. I voluntarily waive any claim against Great Expectations Ministries (GEM) and camp/club personel.
Date_____________ Signature of Parent or Guardian__________________________________