IMPORTANT!

Date(s) of Camp that your minor will be attending:

Which camp is this for? (i.e. Junior Camp, High School Camp, CLC Camp, etc.):

Camper's Name — First:    Last:

Health problems/limitations/allergies:

Any allergies to medication?  Yes             No

If yes, which one(s)?

Health Insurance Company:

Subscriber's Name:

Insurance Company Mailing Address:

Mother/Guardian's Name — First:    Last:

Day Phone:  --

Night Phone:  --

Father/Guardian's Full Name — First:    Last:

Day Phone:  --

Night Phone:  --

Neighbor/Other Relative/Friend to contact if Mother/Father/Guardian can not be reached:
First:    Last:

Relationship to camper:

Day Phone:  --

Night Phone:  --

WHEREAS, the Free Methodist Church in Southern California make their Oak Glen Christian Conference Center facilities available for campers; and in consideration for the privilege of using Oak Glen Christian Conference Center; we do hereby remise, release and forever discharge the Free Methodist Church in Southern California, Oak Glen Christian Conference Center, and all its officers, agents and employees, acting officially or otherwise, from all actions, cause of actions, claims and demands for, upon or by reason of any injury, damage, loss or death which may occur from the use of Oak Glen Christian Conference Center.

In the event of medical emergency, I understand an effort will be made to contact the undersigned parent or guardian.  In the event that I cannot be reached, I hereby give permission to the physician and/or hospital selected by the camp director to give treatment to my dependent named herein in the manner and to the extant necessary in the opinion of said physician an/or hospital.

 

Signature of Parent/Guardian:   ________________________________________

Date: ______________________________________