Application - Elementary - Yellowstone Bible Camp

Application for Elementary Camp
July 7th - 13th, 2019

This camp session is designed for young children in Grades 4th - 6th ("Grade" is defined as the grade to be entered next.)

Campers Personal Information

* Indicates required field

Camper's Name *

First

Last

Date of Birth *

Age *

Choose *

Male Female

Grade *

Date Baptized *

Religious Preference *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Parent's Last Name *

Parents' First Name(s): *

Day Phone Number *

Evening Phone Number *

Parent's Email: *

In Case of Emergency Please Contact:

Name *

First

Last

Relationship *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Home Phone Number *

Work Phone Number *

Family Physician *

Phone Number *

Health/Accident Insurance Company *

Policy Number *

Camper's Health/Medical Information

For the safety and well-being of the youth, an applicant will not be permitted to attend until this form is fully completed and signed by the camper’s parent/guardian. To register on arrival without a parent, you must bring this form, fully completed and signed by parent or guardian. THIS INCLUDES TEENS ALSO. Any medication sent to the camp must be in its original container. Please print instructions on a 3x5” card and place with the medication in a zip-lock bag. Upon arrival at camp, all medications will be collected by the staff medic, who will dispense it to the camper as per the instructions.

Please name all medications brought to YBC to be taken while at camp *

Please name all medications taken in the thirty days prior to arrival at YBC *

Camper's Health History

Das of most recent examination: *

Immunization History (Please give dates for all that apply, put NONE if they do not apply).

DPT Series *

Measles *

Booster *

Chicken Pox *

Hepatitis A *

Hepatitis B *

Mumps *

Polio *

Rubella *

Tetanus *

Meinigitis *

Tuberculin Test Result *

ALLERGIES HEALTH CONCERNS

Please explain any Yes item from above and list other if applicable: *

List any Chronic illness or serious illness in last six months (if none put none) *

List of any special equipment needed *

Recent operations or serious injuries: *

Restrictions/limitations while at camp: *

Immediately upon arrivial please notify camp manager if youth has recently been exposed to a communicale disease.

PARENTAL STATEMENT
To the best of my knowledge this information is accurate and complete. I give my permission for my child to participate fully in YBC activities, subject to limits described herein. In the event of accident or illness in the course of such activity I request that measures be taken without delay as judgment of medical personnel dictates. YBC will not be held responsible for bodily injury, death, or loss of personal property, except to the extent due to the negligence of YBC. I have read, understand, and accept the terms and conditions stated herein and acknowledge that this agreement shall be effective and binding upon the parties during the entire period of attendance at YBC. In case of evacuation due to natural disaster, I agree to immediately pick up (or make arrangements for the pickup of) my child/children at the Livingston church of Christ building or other stated location when notified to do so.
My child and I have fully read the Standards of Conduct located in tne YBC Newsletter or YBC web-site, and he/she will comply with all standards. In addition my signature agrees and grants full right to use the images resulting from the photography/video filming, and any reproductions or adaptations of the images for fundraising, publicity or other purposes to help achieve the aims of Yellowstone Bible Camp. This might inclue (but is not limited to), the right to use them in their printed and online pubilicity or social media, press releases and funding applicaitons.

ELECTRONIC SIGNATURES TODAY'S DATE:

Parent/Guardian *

Month/Day/Year *

Camper *