Student (Camper) Name *

First Name

Last Name

Camper Birthdate *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Parent/ Guardian Name *

First Name

Last Name

Parent/Guardian Phone *

(###)

###

####

Shirt Size (Adult Sizes): *

Small

Medium

Large

X-Large

XX-Large

XXX-Large

XXXX-Large

Church Attending With: *

First Baptist Church Killeen

First Baptist Church Corsicana

New Sunset

Memorial Baptist Church

The Journey Church

Skyline

Airway Baptist Church

Christ Community Church

Emergency Contact Name: *

First Name

Last Name

Emergency Contact Phone: *

(###)

###

####

Emergency Contact Name: *

First Name

Last Name

Emergency Contact Phone: *

(###)

###

####

Doctor/Physican Name: *

First Name

Last Name

Doctor/Physician Phone: *

(###)

###

####

Allergy Triggers: (Check all that apply)

Food

Environmental

Medication

Pets

Other

Over the Counter Medication: Please indicate if any of the following over-the-counter medicine that can be given to your Camper while at camp.: *

These will only be given on an "as needed" basis as determined by the Camp Nurse.

Ibuprofen

Tylenol

Benadryl

Cortisone Cream

Pepto Bismol

Tums

Neosporin/Antibiotic Cream

Calamine Lotion

Imodium

Ant Bite Meds/Cream

None of the Above

Has your Camper experienced, or is currently experiencing any of the following conditions: *

Asthma

Diabetes

Heart Conditions

Epilepsy/Seizures

Bleeding Disorders

History of Concussions

Frequent Headaches

Recent Operation or Medical Procedures

Other

N/A

Please mark any of the following activities that your Camper CAN NOT participate in: *

Zipline

High Ropes Course

Tubing

Canoeing

Swimming

Can participate in all activities

Do we have your permission to post pictures and videos of your Camper on the camp website? *

If No, please provide a photo of your Camper that we can provide our videographer with so they know the faces of Campers not to be used in any camp/promo videos.

Yes

No

Parent Name (Electronic Signature) *

Please sign your name in agreement for use of photos/video.

First Name

Last Name

Student Name (Electronic Signature) *

Please have your Camper sign their name for verification their photos/videos can be used.

First Name

Last Name

Date

MM

DD

YYYY