Participant Form
Bring two notarized originals of this sheet to registration
Attach a photocopy of insurance form or card

Participant Name_____________________________Age_____ Date of Birth ___/___/___ SS#_____________________
Address____________________________________________ City____________________ St_____ ZIP_____________
Name of Church___________________ Address________________________ City__________ St___ ZIP___________
In case of an emergency notify:___________________________ Phone Numbers - Home:(___)____________
Work: (___)_____________Mobile:(___)___________Pager:(___)___________ Other:(___)_____________

Medical Profile

Generally, Participant’s Health is: (Check One) ___Excellent ___Good ___Fair___Poor
If Fair or Poor, please explain your condition:_________________________________________________
______________________________________________________________________________________
List any medical difficulties for which you are currently being treated:_____________________________
Check any of the following that cause you problems and explain:     Asthma____    Sinusitis___    Bronchitis___     Kidney Trouble___

Heart Trouble___    Diabetes___    Dizziness___    Stomach Upset____     Hay Fever____
List any medicines or substances to which you are allergic: __________________________________
List any previous operations or serious illnesses_______________________________________________
List any medications you are currently taking: ________________________________________________
________________________________________________
List any special diet or special needs:________________________________________________________
Childhood Diseases:___Chickenpox___Measles___Mumps___Whooping Cough___Other___________
Date of Tetanus Immunization: ___/___/___
Family Physician_____________________________Phone(____)________________________
Insurance Co._________________________________Policy #___________________________________
Subscriber Name:_____________________Subscriber Number ________Place of Employment__________
Subscriber Occupation:________________________________Work Phone:_________________________

Permission For Medical Treatment, Photograph/Video Notice, and Release and Indemnity

My permission is granted for the camp or event director, church official, any camp or event staffer, or adult present or in charge of
First Aid, to obtain necessary medical attention in case of sickness or injury to my child. Also, I understand that as a participant, my
child may be photographed or videotaped during normal camp or event activities and these photos/videos may be used in promotional
materials.
I, the undersigned, do hereby verify that the above information is correct and I do hereby release and forever discharge LifeWay
Christian Resources of the Southern Baptist Convention, camp or event sponsors, or state conventions and their employees from any
and all claims, demands, actions or causes of action, past, present, or future arising out of any damage or injury while employed by
or participating in this camp or event. I agree to indemnify LifeWay for any and all claims, demands, damages, injuries, costs, suits
or causes of action, past, present, or future, arising out of or caused by my child while participating in this camp or event or while on
property leased or owned by LifeWay.

Complete and sign below (youth under 18 years of age requires Parent/Legal Guardian signature)-
Participant’s Signature________________________________Date: ___/___/___
Parent/Legal Guardian Signature_____________________________ Phone ( ) __________ Date:__/___/___

Notary Acknowledgement (Notary: please affix seal to both sheets.)
State of ____________________ }
County of ____________________}
Personally appeared before me, ________________________, with whom I am personally acquainted, and who acknowledged that
he/she executed the within instrument for the purposes therein contained.
Witness my hand this _____ day of ___________, 20___.
Notary signature: _______________________________
My commission expires:_______________
Rev 9/03