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Camper T-Shirt Size (circle one):                        XS           S              M            L              XL           XXL

Father’s Name ___________________________________   Home Phone ______________________________________

Work Phone _____________________________________   Cell Phone  _______________________________________

Mother’s Name  __________________________________   Home Phone ______________________________________

Work Phone _____________________________________   Cell Phone  _______________________________________

Home Church____________________________________________ City_______________________________________

Camper Health Information:

Allergies, Chronic Illness, or Disabilities _________________________________________________________________

__________________________________________________________________________________________________

Last Tetanus Immunization / booster (must be current) ______________________________________________________

Medication:  Campers are only allowed to bring medication in its original container.  Prescription medications must be in a prescription bottle with the campers name and physicians name and dosage clearly printed on it.  All other medications must have campers name clearly labeled on each item.  All medicine will be collected at registration and dispersed by an appointed staff member.  The camp does carry a variety of over the counter medicines for use.

Routine Medications:

  Camper may be given over the counter medication by an adult sponsor:        Yes          No

My camper, _______________________, has my permission to participate in all planned activities while attending Camp Quarterman.  In signing this application, I certify that the information is correct and give permission for (1) the use of photographs, recording or videos in camp publicity; (2) transportation to be provided in private vehicles for approved off grounds camp activities; (3) and the release of medical records for insurance purposes in case of illness or accident.

I have read and understand the camp information and policies and agree that myself and my camper will adhere to them at all times.  If the camper is in violation of these rules, proper action will be taken.  In serious cases, I understand that the Director has the authority to dismiss the camper and that I am responsible for their immediate transportation home.

Parent/Guardian Signature ___________________________________________ Date _______________________________