Beulahland Christian Camp Registration
Sign in to Google to save your progress. Learn more
Week Attending *
Grade Completed in 2019 *
Full Name *
First and Last
Nickname
Address *
City *
State *
Zipcode *
Age *
Birth Date *
MM
/
DD
/
YYYY
Sex *
T-shirt Size *
First time attending camp? *
Father's Full Name
(or male guardian)
Parent Email *
Father's Cell Number
Father's Work Number
Father's Home Number
Mother's Full Name
(or female guardian)
Mother's Cell Number
Mother's Work Number
Mother's Home Number
Primary Contact for Emergencies *
Provide Contact information if contact information is not listed above
Photos (no names) of campers may be used on camp website to promote Beulahland Christian Camp. Campers may travel to activities off campgrounds. Do you give permission to this? *
Does the child have health insurance? *
Company
Policy Number
Family Physician
Family Physician Phone Number
Immunizations - Month & Year
N/A if not applicable
D.P.T. Series *
Tetanus *
Mumps *
Measles *
Rubella *
Other (specify) *
Allergies
Environmental *
or none
Poison Ivy/Oak *
or none
Insect Stings *
or none
Foods (Please specify) *
or none
Other
Is the Camper bringing medications to camp? *
If Yes, what medication?
This health history is correct to my knowledge, and the person described herein, has permission to engage in all prescribed camp activities, except those listed by me here: *
Signature of Parent/ Guardian (If camper is a foster child, the case worker must sign)
In the event I cannot be reached in an Emergency, I hereby give permission to the physician, selected by the Camp Director/ Manager, to hospitalize, secure proper treatment for, and to offer injection, surgery or anesthesia for the person named above. *
Signature of Parent/ Guardian (If camper is a foster child, the case worker must sign)
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms