Mt Deliverance Worship Center 2907 Pleasant View Road New

Mt Deliverance Worship Center
2907 Pleasant View Road
New Columbia, PA 17856
Office Use
Date rcvd:
2015
Date paid:
570-568-9032
[email protected]
www.mtdeliverance.org
CAMPER APPLICATION
Camp:
Sr Camp
First
MI
Address
Jr Camp
Camp Fee: $130.00
Last
Birth date
City
State
Zip
Age
Gender
M
F
Country
Family E-mail:
Mother/Guardian:
Phone:
Father/Guardian:
Phone:
Emergency Contact:
Phone:
Family Physician:
Phone:
Health Insurance Provider:
Phone:
Group Number:
Policy Number:
List all allergies, restrictions, conditions, or special needs:
Date of Last Tetanus Shot:
Permission is granted to give the following OTC medication under supervision of the camp nurse:
(Generic equivalents may be used) (check all that apply)
Tylenol
Advil
Benadryl
Pepto Bismol
Topical ointments for cuts/abrasions
List all medication being taken during camp including OTC (over-the-counter).
Medications must be in original RX labeled containers.
Medication
Dosage
Frequency
I THE PARENT HEREBY give my permission for my child to participate in any and all activities except as noted
while in attendance at Mt Deliverance Youth Camp, and waive all claims to injury or loss of property arising out
of the activities against Mt Deliverance, its staff, and volunteers. I grant permission for my child/children to attend
any trips off the campgrounds during the course of MDYC.
I hereby consent to allow camp officials to seek and secure medical treatment for my child in the event of an
emergency and further grant my authorization and consent for Mt Deliverance to administer general first aid
treatment for any minor injuries or illnesses experienced by the minor. I fully understand that my family's
insurance will provide primary coverage and the camp insurance policy provides secondary coverage only.
My signature, as parent/guardian of stated child, gives Mt Deliverance permission to use photographs and/or
video of my child for sharing and furthering the ministry of the camping program through print, video, and camp
website promotion.
I have carefully read Registration Information and all related materials.
Print Name: _______________________________________________
Signature: _________________________________________________
Relation to Child: _________________________________________
Date: ______________________