Camp Registration

Pick Which Camp To Register For!

**please note that if you are registering more then one child you will need to fill out this form for each one.**

Please Choose A Camp

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Child Info

First Name:*

Middle Name:

Last Name:*

Male / Female:

Birth Date:

Age:

Street Address:

City

State:

Postcode / Zip:

Child's Home Phone:

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Parent/Guardian

First Name:

Last Name:

Please Select One:

State:

City:

Street Address:

Postcode / Zip:

Home Phone:

Cell Phone:

Work Phone:

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Emergency Contact Information / Alternate Pickup/Release

First Name:

Last Name:

Home Phone:

Work Phone:

Cell Phone:

Relationship To Child?

Please list those people in addition to the parents/guardians who are permitted to pick up your child.

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Medical Release Information

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Insurance Information

Policy Number:

Name Of Health Insurance Provider:

Primary Physician:

Address:

Phone:

Hospital Preference

Please List Any Medical Problems, Including Any Requiring Maintenance Medication (i.e. Diabetic, Asthma, Seizures)

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?

Is your child allergic to any type of food or medication?

I understand that i will be notified in case of a medical emergency involving my child. In the event that i cannot be reached, i authorize the calling of a doctor and previding the necessary medical services in the event my child is injured or becomes ill. Parent's/Guardian's Initials

I understand that Annville Institute / Grace Covenant Ministries will not be responsible for the medical expenses incurred, but that such expenses will be my responsibility as Parent/Guardian. Parent's/Guardian's Initials

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Terms Of Agreement: Photo Release

I hereby give permission for my child to be photographed during Camp JCM. I understand the photos will be used to keep a journal of activities, or reports to our donors and for promotional purposes including flyers, Brochures, Newspaper and on the internet. I understand that although my child's photograph may be used for advertising, his or her identity will not be disclosed, I do not expect compensation and that all protos are property of Camp JCM and it's affiliates. Parent's / Guardian's Initials:

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Just a quick reminder that GCM and its co-organizers are not responsible for the lost or damaged personal property. All scheduled event are subject to change. I understand that not fees will be refunded or transferred unless a child is unable to participate due to an accident or illness per physician orders. Children's' photos and quotes my be used for publicity purposes. In case of an emergency, and if a family physician cannot be reached, I hereby authorize my child to be treated by certified emergency personnel (i.e. EMT, First Responder, And/or Physician).

Parent / Guardian Signature:

Date: