Camper Name
*
First Name
Last Name
Camper Date of Birth
*
MM
DD
YYYY
Grade Completed
*
Youth T-Shirt Size
*
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Parent/Guardian(s)
*
Home Phone
*
(###)
###
####
Emergency Phone
*
(###)
###
####
The camper may be released daily to the following persons:
*
Medical Insurance Carrier
*
Policy Number
*
Does the camper take any daily medications?
*
Name of Drug / Time of Administration / Dosage
Does the camper have any medical conditions that the church or FLLC staff should be aware of?
*
(i.e. allergies, asthma, diabetic)
If you answered yes to the above question, describe your camper's medical conditions here:
I hereby grant permission for this camper to participate in all Evening Camp activities including off-site events. I retain the responsibility for any and all bodily injury, loss, or damage of personal property. I hereby authorize the church to consent to emergency medical or surgical treatment and to routine, nonsurgical medical care for this camper while attending the Evening Camp program.
*
I grant permission for FLLC and host churches to use photos, videos, or other likeness of above Camper for publicity in print or digital form, including the use of social media such as, but not limited to, Facebook, Instagram, and Twitter. FLLC and host churches will not include any identifying information about your Camper.
*
