Mountain Top Baptist Assembly

C asper , W yoming

PO Box 4315 , Casper , WY 82604

(All adults and campers must also fill out this form)

Name:

Birthday:

Circle One : Sponsor Camper

Age:

Grade Completed in School:

Address:

City: State: Zip:

Telephone number:

Church Name & address:

Name and address of Parents/Guardians:

Home Phone: Work Phone: Cell:

In case of an emergency notify the Parents/guardians listed above: ____Yes ___No

If no, List name and address of the person to be notified:

Home Phone: Work Phone: Cell:

MEDICAL profile

Generally, Participant's health is: (check one) ____ Excellent ___ Good ____ Fair ____Poor

If Fair or Poor , please explain your condition: __________________________________________________

_______________________________________________________________________________________

Camper's Physician: ___________________________________________ Phone:_____________________

Insurance Co._____________________________________ Policy # _______________________________

Subscriber Name: ____________________________________ Subscriber Number ____________________

Occupation and Place of Employment _________________________________________________________ Work Phone: ______________

(Copy of insurance card MUST be attached to this form.)

Does the camper have any ALLERGIES (include any medication, food, environmental or latex allergies, etc)

______YES _____NO (If Yes, attach listing of allergies and any necessary medications, type of reaction, and steps to take if reaction occurs.)

Does the camper have any CONTAGIOUS ILLNESSES currently which we should be aware of?

______YES _____NO (If Yes, attach an explanation.)

Does the camper currently take any MEDICATIONS?

______ YES ______NO (If Yes, attach type, dosage, times to be taken, and any relative information concerning the medications.

NOTE: All medication, prescribed or otherwise, must be turned over to the camp First Aid Coordinator at the time of registration, preferable in the original containers. Exceptions must be cleared with the First Aid Coordinator.

Does the camper require any SPECIAL DIET or have any SPECIAL CONDITIONS that we should be informed of? (seizures, diabetes, heart trouble, recent injuries, etc.)

_____ YES _______ NO (If Yes, attach an explanation.)

Please provide the information needed below:

Childhood Diseases: Chickenpox _____ Measles _____ Mumps ________ Whooping Cough _______ Other __________________

Date of Tetanus Immunization: _____/_____/_____

The person named on this form has my permission to engage in all of the camp activities except the following: ______________________________________________Parent/Guardian Initials______

TRANSPORTATION PERMISSION AND EMERGENCY RELEASE

My permission is granted for MTBA or one of their appointed staff, to transport my child/ward as named above, as/if required for any emergency requiring transportation to a licensed medical care center/facility, whereas; I, do hereby give consent for all medical care prescribed by a duly licensed doctor of medicine for my child/ward. This care may be given under whatever situation or conditions are deemed necessary to preserve life, limb, or well-being.

I understand hospital officials prior to treatment of emergency cases require this permission, along with the information provided above.

Signature: _______________________________ Date: ____________________________

Phone #: Home _____________________ Work ________________ Cell: ________________

MTBA Photograph release

I, ____________________, as a parent or guardian, do hereby authorize my child/ward to be photographed and will allow the photograph of my child/ward to be used in MTBA Camp promotional use.

CONSENT OF WAIVER OF LIABILITY

I, the undersigned, do hereby verify that the above information is correct and I do hereby for myself, or my heirs, executors and administrators, waive and release the Mountain Top Baptist Assembly and its employees, representatives, successors, and assigns, from any and all claims, demands, actions or causes of actions, suits, and liabilities arising out of damage or injury while participating in this camp or event. I agree to indemnify Mountain Top Baptist Assembly for any and all damages caused by my child while attending this camp or while on MTBA property.

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 ___/___/____