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