First Baptist Church Albertville - Clover Sites



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Student’s Name_____________________________________ Date of Birth_______________

Last Grade Completed_______________________

Address____________________________________ City_______________ Zip____________

Father Mother

Name_________________________ Name_________________________

Home Phone___________________ Home Phone___________________

Alternate Phone________________ Alternate Phone________________

Email address: ________________________________________________________________

Doctor’s Name________________________ Doctor’s Telephone ______________________

Known Allergies________________________________________________________________

List any medications taken regularly: _____________________________________________

As the parent (or legal guardian) I, the undersigned, certify that my child (named above) has my express permission to participate in Kids Camp 2015.

I understand that the camp leadership will attempt to notify me in case of a medical emergency involving my child. If I cannot be reached, I authorize Kid’s Camp 2015 to secure a doctor or other health-care professional, and I give my permission and consent to the doctor or other health-care professional to provide the medical services he or she may deem necessary. I will notify Kid’s Camp 2015 of any known health considerations that would prevent my child’s participation in an activity. I also give my permission for camp leaders to restrict my child from participating in any activity that they have any questions about for health or other reasons.

A photocopy of this Authorization shall have the same effect as the original.

Signature of Legal Guardian Date

I give Kid’s Camp 2015 permission to take photographs of my camper. Yes / No (circle one)

Attendance

|Monday |Tuesday |Wednesday |Thursday |

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