Discovery Camp Registration Form

NEW COVENANT CHURCH

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REGISTRATION FORM

Parent Information

* Indicates required field

Parent/ Guardian Info *

First

Last

Address *

City *

State *

Zip *

Phone Number *

Email *

Childs Information

Name *

First

Last

Age *

Birthday MM/DD/YYYY *

Medical Information, List all Medicines camper is currently taking as well as dosage! *

Any medical information we may need to know. (illness, allergies, meds needed), please include all food allergies.

Activity Restriction/ Guardian Notes *

Check any medical conditions that previously or currently applies. *

Allergies Asthma Seizures Diabetes Depression Heart Condition Bleeding/Clotting Hypertension Back/Joint Pain Hearing Loss Vision/Difficulties Surgery within a year. None (please check this Box if None)

Insurance Company, Policy Holder Name, Policy or Group Number *

Allergen *

Dairy Wheat Nuts Medicine Plant Animal Insect Other None (please check box if None)

Immunization Information
**Add date administered and dose # to appropriate boxes. (Month,Day,Year)**

Diphtheria/Tetanus/Pertussis *

Polio *

Measle,Mump,Rubella(MMR) *

Hepatitis A *

Hepatitis B *

Varicella *

Meningococcal *

Emergency Contacts Information

Name and Phone Number *

Digital Release

Do we have the permission to photograph your child? *

Do we have permission to use your child's photograph for promotional purposes? *

Submit

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OUR BELIEFS
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