David’s Camp - July 13-18, 2014
Camper Registration
First Camper _________________________________________Age_____ M/F _____
Date of Birth_______________Last Grade _____T-Shirt Size______
Second Camper _______________________________________Age ____ M/F _____
Date of Birth _______________Last Grade _____T-Shirt Size_____
Third Camper _______________________________________Age ____ M/F _____
Date of Birth _______________ Last Grade _____T-Shirt Size_____
ADDRESS___________________________________________________
CITY ____________________STATE _________ZIP ______
HOME PHONE (________)_______-______________
====================================================================================
The Price of the Camp this year will be $
200.00==============================================================================
___ENCLOSED IS $30 PER CAMPER TO RESERVE FOR _____CAMPERS
___ENCLOSED IS _________, THE COMPLETE FEE FOR _____ CAMPERS
MAKE CHECKS PAYABLE TO – DAVID BAKER
SEND WITH COMPLETED FORM TO:
David’s Camp - David Baker- 1050 S. Daley - Mesa, Az. 85204
OR use one of our handy PAYPAL buttons to make your payment or deposit now.
Medical Release Form
At this time we are attempting to get insurance for the camp. Insurance premiums are high, so we are taking our time, trying to get the best rates. Until we acquire insurance we cannot be financially liable for medical attention in case of injury.
Our request is that each camper have their own insurance as their primary provider in case of injury. If you have insurance, please include that information on this form, along with any special medical instructions.
INSURANCE COMPANY _______________________________________________________
POLICY # _____________________________________
RESPONSIBLE PARTY ____________________________
NO CAMPER CAN BE ACCEPTED WITHOUT THE FOLLOWING COMPLETED.
I hereby authorize the physicians, nurses and assistants of the local hospital to perform all treatments and procedures deemed necessary in case of emergency for:
1)_________________________________Date of last Tetanus shot: ___________
2)_________________________________Date of last Tetanus shot: ___________
3)_________________________________Date of last Tetanus shot: ___________
Parent or Legal Guardian signature __________________________________________
Relation to Camper ___________________In case of emergency notify:
1)_______________________________Phone # ______________
2)_______________________________Phone # ______________
All campers on this form are in good health and are able to participate in normal camp activities. Below are listed any special health alerts camp counselors, or medical technicians need to be aware of (allergies – including bee stings, asthma, regular medication, etc.).
----------------------------------SPECIAL INSTRUCTIONS----------------------------------