Register Camper

Subject:

Parent or Legal Guardian's Name:

Parent or Legal Guardian's Email Address:

Camper Information
Please register my son/daughter for SSBC.

Camper Name:

Age:

Birth Date:

Gender: (Please check one)
Boy
Girl

Address:

City:

State:

Zip Code:

Home Phone Number:

Cell Phone Number:

Work Phone Number:

Desired Camp Dates: (Please check one)
Boy's Camp 1 (Monday 6/4/2012 - Friday 6/8/2012)
Boy's Camp 2 (Monday 6/18/2012 - Friday 6/22/2012)
Boy's Camp 3 (Monday 7/9/2012 - Friday 7/13/2012)

Girl's Camp 1 (Monday 6/11/2012 - Friday 6/15/2012)
Girl's Camp 2 (Monday 6/25/2012 - Friday 6/29/2012)
Girl's Camp 3 (Monday 7/16/2012 - Friday 7/20/2012)

Advanced Camps (Must be 13 or older to attend - Invitation Only):
     Boy's Fish/Wood Working Camps (Monday 7/30/2012 - Friday 8/3/2012)

     Girl's Cook and Sew Camp (Sunday 7/22/2012 - Wednesday 7/26/2012)

Transportation is provided to and from camp. We will mail pickup locations and times the week prior to camp.

Do you need transportation?: (Please check one)
Yes
No

Pickup Locations: (Please check one)
Boonville
Buffalo
Columbia
Independence
Jefferson City
Sedalia (Housing)
Sedalia (K-Mart)
Springfield
Versailles
Warsaw

Sagrada Scholarship Bible Camp does not charge for camping, but relies on God and His people to provide.

Parental Permission and Release:

I/We, the undersigned, understand that while attending the Sagrada Scholarship Bible Camp, of Sagrada Missouri, the below named child may be involved in various activities, including and not limited to swimming, boating, hay rides, fishing, archery, and other traditional camp activities. I/We have familiarized myself/ourselves with these programs and activities, the physical terrain, and have reviewed the written materials provided by the camp, including but not limited to the camp brochure. In consideration of Sagrada Scholarship Bible Camp, Inc. allowing the child to attend the camp for the periods specified above and to participate in the activities. I/We do hereby grant permission for the child to attend and to participate fully in said activities. I/We understand and accept the risks and dangers involved in such activities and do hereby release Sagrada Scholarship Bible Camp, Inc. its officers and directors, its employees, agents, and the camp staff, from any and all claims, demands, actions, causes of actions of any sort, for injuries or death sustained by myself/ourselves/or the child, whether such injury occurs on or off the camp property. I/We have instructed my/our son/daughter to obey the rules of Sagrada Scholarship Bible Camp. I/We give permission of medical treatment which my be needed for their welfare.

I have read and understood the forgoing permission/release form.

Full Legal Name of Parent/Guardian: *
(Entering Full Legal Name in this field constitutes a Legal Signature for Permission and Release)

Relationship to Child: *

Date: *

If for any reason you do not want your child's picture used in promotional and sponsorship material, check below:
Do not use photo

Health History
Please fill this part out to the best of your ability.

Emergency Contact #1 Name:

Emergency Contact #1 Home Phone Number:

Emergency Contact #1 Cell Phone Number:

Emergency Contact #1 Work Phone Number:

Emergency Contact #2 Name:

Emergency Contact #2 Home Phone Number:

Emergency Contact #2 Cell Phone Number:

Emergency Contact #2 Work Phone Number:

Family Physician:

Family Physician Phone Number:

Do you carry medical insurance: (Please check one)
Yes
No

Carrier and Policy Number:

Health History:
Please check Yes or No for the following. If the answer is Yes, please give approximate date.

Frequent Ear Infections: Yes No

Convulsions/Seizures: Yes No

Bleeding Disorder: Yes No

Menstrual Disorder: Yes No

Asthma: Yes No

Measles: Yes No

Mumps: Yes No

Heart Defect/Disease: Yes No

Diabetes: Yes No

Hypoglycemia: Yes No

Mononucleosis: Yes No

Chicken Pox: Yes No

German Measles: Yes No

Hay Fever: Yes No

Allergies:
Please check Yes or No for the following. If the answer is Yes, please provide details.

Insect Stings: Yes No

Penicillin: Yes No

Other Drugs: Yes No

Immunizations:
Are they up to date as required by public schools: Yes No

Surgery or Serious Illness: (Please check one)
Yes No
What type and date?

Disability or Chronic Illness: (Please check one)
Yes No
If so, please explain

Does the camper have any physical limitations or medical conditions preventing them from performing certain types of activities relating to children or youth? (Please check one)
Yes
No

Are there any activities limited or encouraged at the advice of a physician? (Please check one)
Yes
No
If so, please explain

Dietary Modifications or Food Allergies? (Please check one)
Yes
No
If so, please explain

Current Medications (include instructions)? (Please check one)
Yes
No
If so, please explain

This health history is correct to the best of my knowledge and the person herein described is fit to engage in all the prescribed activities. (Please check one)
Yes
No
If not, please explain

RELEASE: I do hereby release SSBC Inc., and its staff and officers from any liability in the case of accident, illness, or injury during participation at camp, whether such occurs on or off camp property. I authorize any medical treatment that may be needed for my/his/her (enter camper name) welfare.
(Please check one)*
Yes
No

Full Legal Name of Parent/Guardian: *
(Entering Full Legal Name in this field constitutes a Legal Signature for Release)

Date: *

Comments: