Please print this page, fill it out and bring it to camp

                       DO NOT SEND IT   

DON'T FORGET STEP 3 AT

           BOTTOM OF PAGE

 Free Summer Camps for Kid's  

   ADD  CAMP DATE:                           2010       

  

CHILDS  NAME                                                                    

 ADDRESS                                                                                

 CITY                            ST                            ZIP                   

 PHONE                                      Birthday                 M/FM 

 PHONE                                            

 

 PLEASE CIRCLE THE FOLLOWING THAT APPLY:

 HEART PROBLEM   -     DIZZINESS  - ALLERGIES? 

 ASTHMA  -   NOSE BLEEDS           

 Is camper allergic to any  medication? 

             YES           NO               WHAT                                               

             We accept NO Dr. prescribed medication of any kind at camp.     We will NOT be held liable for Dr. prescribed medication. 

 Tetanus shot up to date?        yes          no      

 Insurance:  Please give us the name of camper's Ins.       Company                             

 Name of Insured                                                                 

I hereby give my consent for my child to attend Teen Round-Up  camp and authorize Kim or Roxanne Kerley to administer medical  care in case of emergency and I cannot be reached.

Signed  (Parent/Guardian)       _________________    

I give my permission for local newspapers and media to  photo my child to publish in papers and TV during their stay at Teen Round-Up                                    
 PARENT OR LEGAL GUARDIAN_______________________

LAST CLICK HERE! FOR STEP THREE