Camp Registration

Camper Name

Age (As Of June 20th)

Grade In Fall 2022

Gender Gender Male Female

Are You Coming With A Church Group Are You Coming With A Church Group Yes No

Mailing Address

Pastor's Name

Church Name

T-Shirt (Additional $10 For A T-Shirt) T-Shirt (Additional $10 For A T-Shirt) Yes No

T-Shirt Size T-Shirt Size Child Size Adult Size

Shirt Size Shirt Size Small Medium Large X-Large XX-Large 3X-Large 4X-Large

Emergency Contact #1 (Phone Number & Relation To The Camper)

Emergency Contact #2 (Phone Number & Relation To The Camper)

Family Physician & Phone Number

Insurance Company Phone Number & Policy Number

Does Your Child Fall Out Of Bed Frequently? Does Your Child Fall Out Of Bed Frequently? Yes No

Any Other Medical Conditions (If none write "none)

Does Your Child Have A History Of Seizures? Does Your Child Have A History Of Seizures? Yes No

Child's Allergies (If none put "none) (Allergies, please include reaction)

Does Your Child Have Dietary Restrictions? Does Your Child Have Dietary Restrictions? Yes No

If Needed Which Do You Prefer? If Needed Which Do You Prefer? Tylenol Aspirin Motrin

If Yes, please explain, If No, Write "none"

Disclaimer: For the health and safety of all campers, Mt. Zion Baptist Church Camp requests that people with contagious conditions or diseases not be sent to or visit Camp. Furthermore, if any potential Camper has had any illness in the two weeks prior to Camp, we request that they not participate in Camp. We appreciate your cooperation and understanding in this matter of public health. Over the counter medications will be provided by our Health Services Department if needed. Please, do not send medication with the camper unless prescribed by a Doctor. All medications must be in their original labeled containers and in a Ziploc plastic bag labeled with the camper’s name and church name. In case of a medical emergency, I understand that every effort will be made to contact the emergency contacts listed above. In the event they cannot be reached, I hereby give permission to the Physician selected by the Camp Director to hospitalize, secure proper treatment, order injection, anesthetize, or perform surgery deemed necessary for my child. I also confirm that the medical information I provided is complete and accurate. Disclaimer: For the health and safety of all campers, Mt. Zion Baptist Church Camp requests that people with contagious conditions or diseases not be sent to or visit Camp. Furthermore, if any potential Camper has had any illness in the two weeks prior to Camp, we request that they not participate in Camp. We appreciate your cooperation and understanding in this matter of public health. Over the counter medications will be provided by our Health Services Department if needed. Please, do not send medication with the camper unless prescribed by a Doctor. All medications must be in their original labeled containers and in a Ziploc plastic bag labeled with the camper’s name and church name. In case of a medical emergency, I understand that every effort will be made to contact the emergency contacts listed above. In the event they cannot be reached, I hereby give permission to the Physician selected by the Camp Director to hospitalize, secure proper treatment, order injection, anesthetize, or perform surgery deemed necessary for my child. I also confirm that the medical information I provided is complete and accurate. Acknowledge

Agreement: I agree that I and my children will follow all guidelines including standards for conduct and dress set forth by Mt. Zion Baptist Church Camp. I acknowledge and accept the risks of physical injury associated with participation at Camp. The participant (or Parent/ Guardian) accepts personal financial responsibility for any injury regarding Camp and further, will hold harmless Mt. Zion Baptist Church Camp, Penn Grove Retreat, or any of their representatives for any injury or illness related to Camp. This includes any illness or injury due to the current Coronavirus situation. I agree that I am aware of the risks associated with the current Coronavirus situation, and I agree that my children are participating in Camp at our own risk. I understand that Mt. Zion Baptist Church of Brogue, PA, will not participate in any form of “contact tracing.” Agreement: I agree that I and my children will follow all guidelines including standards for conduct and dress set forth by Mt. Zion Baptist Church Camp. I acknowledge and accept the risks of physical injury associated with participation at Camp. The participant (or Parent/ Guardian) accepts personal financial responsibility for any injury regarding Camp and further, will hold harmless Mt. Zion Baptist Church Camp, Penn Grove Retreat, or any of their representatives for any injury or illness related to Camp. This includes any illness or injury due to the current Coronavirus situation. I agree that I am aware of the risks associated with the current Coronavirus situation, and I agree that my children are participating in Camp at our own risk. I understand that Mt. Zion Baptist Church of Brogue, PA, will not participate in any form of “contact tracing.” Agree Disagree

Parent's Name (By typing your name you are giving permission for your child to attend camp)

Today's Date