Lake Church - Youth Camp Form

Youth Camp Registration Form

Camper information

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Gender

Birthdate

Shirt Size

Guardian Information

First Name

Last Name

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

Phone Number

Medical Information

Students Medical Insurance

Name of Family Physician

Carrier Name

Group Policy Number

Name of Policy Holder

First Name

Last Name

Physical or Mental Limitations

List Allergies

Are the campers immunizations up to date?

Yes

No

Second Emergency Contact

First Name

Last Name

Phone Number

Signature