This form is to be completed by applicant’s Parent/Legal Guardian and signed by both the Parent/Legal
Guardian and the Camper.
All information must be complete. Incomplete applications will incur a $3 charge upon receipt of the
Missing information must be received before application will be accepted.
DVD Qty (optional $15/ea
Lakeview Camps only)
Name Phone Camp Week Attending Week 2Address City State ZipMale Female Date of Birth / / Grade next fall T-shirt Size
S / M / L / XLEmail address firstname.lastname@example.org Church TheChurchOfCorinth Church City Corinth, TXIs there anyone your child should
be released to? Yes No If yes, Name(s)
The camp insurance carrier does not cover pre-existing medical conditions.
IMMUNIZATIONS: List the last date given (the State of Texas requires the dates to be listed).Oral Polio DPT (Diptheria/Pertussis/Tetanus) MMR (Measles/Mumps/Rubella)[ We have chosen not to immunize. Parent Signature Date
]CHRONIC/RECURRING CONDITIONS: Check all that apply.
Asthma/Respiratory ProblemsBleeding/Clotting DisorderConstipationDiabetesEar InfectionEmotional DisturbancesEpilepsyFaintingHeadachesHearing ImpairmentHeart DiseaseHypertensionKidney Disease/Bed WettingMusculoskeletal DisorderNosebleedSeizuresSickle Cell Trait or DiseaseSpecial Dietary RegimenOther
Date of last examination Are activities restricted? Yes NoIf yes, please explainALLERGIES:
AnimalsFoodInsect BitesMedicines/DrugsPlantsPollenHay FeverOther
Can your camper swim? Yes No A littleMay your camper swim at camp? Yes NoCheck if your child wears Contact Lenses Glasses Dental AppliancesMay be given Tylenol? Yes No May be given Benadryl? Yes No May be given Ibuprofen? Yes NoMy Camper may be given over the counter, non-prescription medications or applications, not to exceed the recommended dosage for stomachdiscomfort, burns, cuts, insect bites, rash or scrapes. Yes No
Physician Name PhoneHealth Insurance Carrier Policy/Group #
Name Day Phone Evening PhoneIf Parent/Guardian cannot be contacted, please notify:1) Name Day Phone Evening Phone2) Name Day Phone Evening Phone
I authorize the adult in charge to consent to medical treatment when either my assignee or I cannot be contacted. I understand that every effort will be made tocontact me regarding medical attention given to my child. I also understand that participants at Lakeview Camp are liable for damage caused intentionally ormaliciously. Damage caused by a participant will be billed directly to the participant responsible and their legal guardian. I understand that youth camp is a voluntaryactivity. Student must be willing to cooperate with the overall spirit and schedule of the camp. Finally, I understand that every effort will be made to room churchgroups in the same cabins. However, due to the structure of the camp and the limited number of beds, this is not always possible. I also grant my permission toNorth Texas District Council to use photographs (individual or group) and/or multimedia images and recording in the best interest of the North Texas DistrictCouncil. I have reviewed the camp information sheet and gone over the camp and dress code policies with my child. Camper signature required: Agree to abide bycamp and dress code policies.
Parent Signature Date
(signature required if camper under age 18)
Camper Signature Date