registration & release
Camper Information:
Participant Name: ______________________________________ Parent/Legal Guardian Name: __________________________
Address: _______________________________________________ City: ________________________ State: _____ Zip: _________
Home Phone: ___________________________ Email: ________________________________________ Male: ____ Female: ____
Birth Date: ________________ Last Grade Completed: ________ School: _____________________________________________
In Case of Emergency:
Contact Name: __________________________________________________________________ Relationship: _________________
Address: ________________________________________________________________________________________________________
Home Phone: ___________________________ Work: _____________________________ Cell: _____________________________
Medical:
Please list allergies or medical conditions we should be aware of: _________________________________________________
_________________________________________________________________________________________________________________
List all medications currently taking: ____________________________________________________________________________
_________________________________________________________________________________________________________________
(Parents/Campers are required to give all medications to the camp nursing staff at registration. The nursing staff will
insure proper usage and dosage.)
(Campers will not be allowed to keep any prescription or over the counter medications with them. The following over the counter
medications will be dispensed on an “as needed” basis unless noted by parent/legal guardian: Tylenol, Motrin, Pepto-Bismol,
Imodium-AD.)
Family Physician: __________________________ Physician Phone: ______________________ Fax: _______________________
Health Insurance Carrier: _________________________________ Name of Primary Insured: ____________________________
Contract Number: ______________________________________________ Group Number: ________________________________
Consent Agreement:
I hereby give my permission for the child listed above to ride the bus, van or vehicle, participate in all activities during
the 2017 CityHope Youth Camp, and any other activities corresponding with this outing. I understand that my
child(ren) will be under adult supervision at all times. I further understand that in signing this permission slip, I
release and hold harmless CityHope Church, and any representat...
