WORSHIP RETREAT at Big Sandy Camp

Camper Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

*

Male

Female

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Retreat Date *

MM

DD

YYYY

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

HEALTH HISTORY: Check any that apply

Recent Surgery

Fainting

Heart Trouble

Migraines

Head Lice

Asthma

Mental Health / Behavioral

Kidney Trouble

Chronic Illness

Convulsions/Seizures

Diabetes

Nosebleeds

Bedwetting

Nightmares

Sleepwalking

ALLERGIC TO:

Food

Medicine

Environment

IMMUNIZATION RECORD: Check if immunized against

Chickenpox

Hepatitis B

Polio

MMR

Diptheria, Pertussis, Tetanus

Date of Last Tetanus Booster

MM

DD

YYYY

*

Name of Parent or Guardian

First Name

Last Name

*

By checking this box, I agree to the statement(s) made above and certify that the information listed above is correct to the best of my knowledge.