General Information

Camper:_______________________________   Going into Grade:_____________

Full Address:__________________________________________________________________

Art Tack (check only one)   T-Shirt size ____________________________

___ Elementary  ___ Clay   ___ Sock Puppet  ___Wood/Metal ___ Stain Glass ___ Culinary
       ___ Guitar   ___ Vocal   ___ Drum

Person to contact in case of emergency: __________________________________

Phone:_________________________ Cell Phone _________________________________

Alternate Contact Person:_____________________________ Phone:__________________

Medical Information
If your child should require medical attention for injuries received or illnesses contracted prior to activity, please
send us the necessary information to give him/her proper medical care during his/her time with the youth ministry
activity.  If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury
while your child is at the activity.

Name of insurance company______________________________________________________________

Policy# ________________________ Group# _______________________

In whose name is the insurance? __________________________________________________________

Family Doctor ______________________________ Phone # ____________________

Dentist ___________________________________ Phone # ____________________


Health History
Any pre-existing or present medical conditions: ______________________________________________
____________________________________________________________________________________

Name and dosage of any medications that must be taken _______________________________________
____________________________________________________________________________________

List Allergies: _________________________________________________________________________

Any major illnesses during this past year? ___________________________________________________

Date of last Tetanus shot: ____________________ Contact lenses Yes / No

Any activity restrictions?  Yes / No      If yes, what: ___________________________________________

Release and Waiver

I understand that in the event medical intervention is needed, every attempt will be made to contact immediately the
persons listed on this form.  In the event I cannot be reached in emergency during the activity dates shown on this
form, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, to secure
medical treatment and/or order injection, anesthesia, or surgery for my child as deemed necessary.
I understand all reasonable safety precautions will be taken at all times by the Eastport Baptist Church and its
agents during the events and activities.  I understand the possibility of unforeseen hazards and know the inherent
possibility of risk.  I agree not to hold Eastport Baptist Church, its leaders, employees, and volunteer staff liable for
damages, losses, diseases, or injuries incurred by the subject of this form.

Signature of parent/guardian:__________________________________________ Date: ______________
Art Camp Registration
Send this registration form with fees to
Eastport Baptist Church
PO Box 2, Eastport, MI 49627