Name: *

Camper Application Form

Hillcrest Baptist Camp-Assembly, Inc. - R.R. 1, Box 254A, Cave-in-Rock, IL 62919 - (618) 289-3036

Birthdate: *

Age: *

Gender: *

Parent's Name: *

Address: *

Country

City

State

Zip code

Home Phone Number: *

Work Phone Number: *

Cell Phone Number: *

Email Address: *

Event Date: *

Church Information

Church Name: *

Church Address: *

Country

City

State

Pastor's Name: *

Church Phone Number: *

Please list any general, medical, or food allergies:

Church Email Address: *

Church Association: *

Country

City

State

Health History

Please list any health problems:

Additional Notes:

Recent Exposures:

Operations or Serious Injuries and Dates:

Are all of the camper's immunizations up to date? *

Yes

Date of Last Immunization: *

Has your child had head lice in the last 30 days? *

Yes

Please list any current medications the camper takes (Prescriptions and Over the Counter medications) (Please give dosage instructions):

Restrictions:

Family Physician's Name: *

Phone Number: *

Other Information:

In case of an emergency and when a parent or guardian cannot be reached, I give permission to contact the following person about my child's care:

Name: *

Phone: *

Relationship: *

Medical Insurance

Insurance issued in the name of: *

Address

Apt, suite, etc.

Country

City

State

Zip code

Name of Insurance Company: *

Policy Number: *

Please enter your full name below to verify this information is correct: *

Please check the box below: *

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The above health history of the person herein described is correct and has permission to come to Camp and engage in all prescribed activities as noted and to take over-the-counter medications as listed on this form if the Camp medical person deems necessary. Dosages will be administered according to the directions on the bottle unless a physician directs otherwise. In an emergency the Camp authorities have my permission to take the camper to the nearest medical hospital or facility. I hereby give permission to the Camp Directors, Camp Leaders, or the medical personnel selected by Hillcrest or their designee to administer the above medications or others and to obtain tests and treatment for my camper in the event of an emergency and I cannot be reached. I further authorize the release of the above medical information to appropriate personnel and/or health coverage insurance companies. I do hereby release from all claims and forever hold harmless the directors, officers, employees and all volunteer staff from Illinois, other states and nations assisting Hillcrest Baptist Camp-Assembly, Inc., churches, associations and conventions from any and all claims including media and other claims and demands for personal injury, sickness, death etc., as well as property damage and expense of any nature incurred by my camper while attending camp, overnighter, orientation, or staff training. I understand my insurance will be considered the primary carrier. I further understand in the event no insurance is provided by the parent, family, guardian, etc. I shall be responsible for any medical expenses. My camper understands and agrees to abide with the restrictions placed on their activities by their parent/guardian/representative and/or Camp or Hillcrest authorities.