FOR OFFICIAL USE ONLY

National Youth Camp 2022 Registration Form Date Received:_____________

“Jesus is Coming! Get Involved!” PAID:  $45
July 28-31, 2022 R. #: ______________
INSURED:  Yes  No
Progresso Village, Corozal District MEDICAL FORM:  Yes  No
CAMPER’S INFORMATION CONSENT FORM:  Yes  No

Last Name:____________________________________ First Name:____________________________________

Church___________________________________________________________ Region_____________________
Date of Birth (D/M/Y): / / Post(s):____________________________________________________
Phone number: _______________________________ E-mail:_________________________________________
PARENT/GUARDIAN INFORMATION
Last Name _____________________ First Name _____________________ E-mail _____________________
Phone number __________________ Work number ___________________ Cell number ________________

INSURANCE INFORMATION REGISTRATION FEE

Insured?  Yes  No Regular  $45
Church: ____________________
(Registration Deadline July 14th, 2022)

AUTHORIZATION OF CONSENT (Under 18 years) (Print child’s name)

I, the undersigned parent/guardian of _____________________________________, a minor, do grant permission

for her/him to attend the National Youth Camp from July 28-31, 2022 at Progresso Village, Corozal District.
He/She DOES/DOES NOT have my permission to swim.

_______________________________ _____________________
Signature of Parent/Guardian of Minor Date

_______________________________
Camper’s Name

MEDICAL INFORMATION
Full Name:________________________________________________ Date of Birth (D/M/Y): / /
Church___________________________________________________________ Mission _____________________
EMERGENCY CONTACT INFORMATION
Full Name ______________________________________________ Contact No. _______________________
ALLERGIES:  Yes  No RESPIRATORY CONDITION:  Yes  No
DIABETES:  Yes  No EPILEPSY:  Yes  No
HEART CONDITION:  Yes  No DRUG REACTIONS:  Yes  No
ASTHMA:  Yes  No SKIN DISORDER:  Yes  No
Other: ____________________________________________________________________________
If you have answered yes to any of the above, please elaborate below:
Condition:______________________________________________________________________________________________
______________________________________________________________________________________________________
Medication Required: ____________________________________________________________________________________
Drug/Food Reactions: ____________________________________________________________________________________