Camp Registration 2015 - Chicago Alive Youth Camp

CHICAGO ALIVE YOUTH CAMP
REGISTRATION AND HEALTH FORM
Each item must be completed by a parent or guardian. Incomplete forms will be returned.
Name ______________________________________________________
Age___________
Date of Birth ____/____/____
Sex M ___ F ___
Address ______________________________________________________________________________
City _________________________________________ State _____ Zip ________________________
Home Phone No. _______________________ Work No. _______________________
C&MA Church Name ___________________________________________________________________
EMERGENCY INFORMATION
People to contact in order of importance in an emergency:
1. Name _____________________________ Phone (___)______________________________
2. Name _____________________________ Phone (___)______________________________
In addition, list below the names of adults to whom your child may be released.
1. Name _____________________________ Phone (___)______________________________
2. Name _____________________________ Phone (___)______________________________
HEALTH HISTORY
Any operations or serious injuries (dates):__________________________________________________
____________________________________________________________________________________
Any chronic or recurring illness: __________________________________________________________
Date of last tetanus shot: _______________________________________________________________
SPEACIAL MEDICATIONS
Indicate below any special medications required by and accompanying this camper to camp. SPECIFIC
written instructions MUST be included and medicine MUST be in the original container!
Medications __________________________________________________________________________
Instructions __________________________________________________________________________
Please indicate any medicine or food allergies (if Allergies, type of reaction), activities to be encouraged
or restricted, or any other information which will meet this camper’s needs:
PARENTS AUTHORIZATION
My child has permission to attend and engage in all prescribed camp activities except any that I have
noted in writing. Further, in the even of routine medical need or an Emergency, if I cannot be reached, I
hereby give permission to the physician selected by the camp director to hospitalize, secure proper
treatment for, and to order injection, anesthesia, or surgery for my child as named above. I also give
permission for the Chicago Alive Camp Leadership Team to search my child’s personal possessions and
understand that any child found possessing illegal drugs or weapons will be sent home immediately.
Signature __________________________________________ Date _______________________
CHECKS ARE TO BE MADE OUT TO: Chicago Alive Youth Camp
RETURN REGISTRATION FORM WITH CHECK TO YOUR CHURCH REPREPRESENTIVE OR PASTOR
JIM LARKIN – (773)587-1049