|
First
Name:
|
|
| Last
Name: |
|
| Date
of Birth: |
|
| Age
on July 17th, 2011: |
|
| Sex: |
|
| Grade
Just Completed: |
|
| T-Shirt
Size: |
|
| Parent's
/ Guardians Name: |
|
| Mailing
Address : |
|
|
E-mail
Address:
|
|
|
Home
Phone:
|
|
| Cell
Phone: |
|
| Name
of Person Picking up Camper: |
|
| Pick-up
Friday Night or Saturday Morning: |
|
| Campers
Home Church: |
|
| Swimmer
or Non Swimmer: |
|
| Emergency
Contact Name: |
|
| Emergency
Contact Number: |
|
| Medications: |
|
| Allergies: |
|
| My
permission is granted for the Mount Moriah Campground director
or staff person in charge to obtain necessary medical attention
in case of sickness or injury to my child. (Type either Yes
or No) |
|
| |
|
| Insurance
Company Name: |
|
| Policy
Group Number: |
|
| Child's
Physician: |
|
| Child's
Physician's Phone Number: |
|
| |
|
| I,
the undersigned, do hereby verify that the information given
to the camp is correct and I do release and forever discharge
all sponsors and board members of the Mount Moriah Campground
from any and all claims, demands, actions, or cause of action,
past, present, or future, arising out of any damage of injury
while participating in the Mount Moriah Camp Meeting. |
| Today's
Date: (put today's date in the box) |
|
| Signature:
(Type your first and last name) |
|