Spiritual Warfare Camp Camper Application 2019

July 22th - July 27th 2019
Lost Valley Camp 5274 M-32  Gaylord, MI 49735   
Phone: 1-231-546-3851

NAME____________________________________________

ADDRESS____________________________________________________

HOME PHONE(____)____________CELL(____)__________________
GRADE THIS FALL must be entering 8-12 grade OR Young adults 19-24 years old.    AGE___________
SEX: M or F  HOME CHURCH________________________CITY______________

ROOMIE REQUEST (max 1) _______________________________
Note: Late registration may not guarantee  

HEALTH INFO.
MARK IMMUNIZATIONS RECVD. (NOT REQ.)     DPT.  TET.  POL.  TB.  MES.
ALLERGIES: STINGS_____PENICILLIN_____ OTHER_____ HEP B VACC?_____
CURRENT MEDICATIONS TAKING_______________________________________
CURRENTLY BEING TREATED FOR INFECTIONS DES?_______WHAT________
BEHAVIORAL PROBLEMS OR PHYSICAL LIMITATIONS:__________________________________________________________

HAVE OR SUBJECT TO:
EAR INFECTION_____DIABETES_____SEISURES____NONE____OTHER_______
IN CASE OF EMERGENCY
PARENT OR LEGAL GUARDIAN WILL BE CALLED FIRST,THEN WHO:
NAME______________________CELL(____)____________HOME(___)___________
NAME______________________CELL(____)____________HOME(___)___________
DO NOT RELEASE CHILD TO…(GIVE NAMES NOT TO RELEASE CHILD TO)
NAME________________________________________
PARENTAL CONSENT/EMERGENCY INFORMATION
“I GIVE PERMISSION FOR MY CHILD TO ATTEND CAMP. I AUTHORIZE THE CAMP TO CONSENT EMERGENCY MEDICAL OR SURGICAL TREATMENT OF MY CHILD, AND TO ROUTINE, NON-SURGICAL MEDICAL CARE. I ALSO AGREE TO PAY FOR THE PERFORMANCE OF SUCH TREATMENT, ANESTHETICS, AND OPERATIONS AS DEEMED NECESSARY IN THE OPINION OF THE ATTENDING PHYSICIAN.”

Printed name of parent, legal guardian, or authorized person _________________________________
Signature of person named above________________________________  
   
Ins. Co._________________

Policy#_________________________ 
 Name of insured_____________________________________________
Parental authorization is required for emergency medical treatment. No physicals needed.
“I agree to obey the standards for campers which will be given to me in orientation”
 camper signature_______________________________________(this is required)

Payment information:  $200.00 payable by check to: Spiritual Warfare Camp
payment must be postmarked by July 13th 2018. Walk-ons & late payment tuition will be    $220.00
Mail payments to: Bethany Eagles Nest Church 2740 Nadeau Rd. PO Box 245 Monroe, Mi 48161 ATTN: Pastor Louie    Questions: call (734) 735-6777
Sign in time on Monday WILL BE 1-4pm!*Graduation will be Sat. at 11am. EVERYONE WELCOME!
__________________________________________________________
MEDIA by signing form you agree to allow us to use any media coverage taken during event for future promotions and publications. 

Thank you