Camp Laurel Registration and Health Form
The Tazewell District Camp
4694 Laurel Fork Road, Rocky Gap, VA 24366
www.explorecamplaurel.com (276)928-1821
Camp____________________________________ Date of Camp________________________
Campers Name __________________________ Cost & Payment _____________
Address ____________________________________________________________
City _______________________________ State _________ Zip _______________
Birth date ______________ Age ______________ Gender ___________________
Grade in School in Fall of 2008 __________ Home Church ___________________
Parent/Guardian ____________________________________________________
Phone _________________ Daytime_______________ Cell phone ____________
Family Insurance Company ________________________ Policy # _____________
Insurance Subscriber’s Name _______________________SS# ________________
In an emergency situation, other contacts:
Name __________________________________________Phone _____________
Name__________________________________________Phone______________
Has Camper ever had the following:
Ear infections ____ Chickenpox ____ Measles ____ Frequent Headaches ____ Mumps ____ Convulsions ____
Bleeding Disorders ____ ADD/ADHD____ Fainting ____ Operations ____ Diabetes ____ Serious Injuries ____
Mouth Braces ____ Is camper a sleepwalker ____ Chronic or recurring illness __________________________
Emotional of behavioral concerns ________________________ Can camper swim ______________________
Is campers shots up to date_________ Last tetanus shot given ____________ Is Camper afraid of dark ______
Does Camper require a special diet _____ Does camper need an epi-pen _____ Does camper have a kit _______
Does Camper need to take medication while at camp? _____ Please bring with complete directions for give medications and give them to the counselor
Has Camper ever had an allergic reaction to: ____________________ Describe reaction: ________________________________________________________________________
Over-The-Counter Medications—By answering the appropriate line, I give permission for me/my child to receive the following over-the-counter medications according to the specific direction on the product label unless otherwise directed by a physician
Symptom Medication (Please write yes or no)
Headache, fever Acetaminophen (Tylenol) ___________
Cramps, Muscle Pain, Inflammation Ibuprofen__________
Upset stomach Maalox____________ Mylanta___________
Diarrhea Kaopectate __________
Localized Allergic Reaction Benadryl_______
Sore Throat Sore Throat Lozenge ________
Itching (Rash) / Insect Sting Calamine Lotion ________ Sting Kill _________
Sun Burn Protection Sunscreen Lotion _______
Sun Burn Aloe ________
This health history is correct so far as I know.
In signing this authorization, I acknowledge that I have read the event description and am aware that the activities associated with this cam and the inherent risks including damage to property, personal injury, and even death. In consideration for being permitted to participate in this camp, I agree to assume all such risks and herby release and discharge Camp Laurel Staff and the Tazewell District UMC along with it’s boards, trustee, and employees, agents and other aids and/or volunteers from and and all liability for any and all damage, loss, injury, or death of every kind and nature whatsoever which in any way arises out of participation in these events.
The person herein described has permission to engage in all prescribed camp activities except as noted.
I hereby give permission to the camp to provide routine health care, administer prescription drugs and seek emergency medical treatment include X-rays and/or routine tests. In event I cannot be reached in an emergency, I hereby and/or anesthesia and/or surgery for me/or my child as name above.
I give permission for me/my child to be transported in a private vehicle.
I give permission for photographs taken of me/or my child to be used for camp publicity, printed or electronic.
Camper Signature ________________________________________________
Parent/Guardian Signature _________________________________________
Date ______________________
Cabin assignment ______________________ Counselor ____________________________________
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