Camper Information

  Name (First and Last)

  

  Church


  City


  Age

  

  Date of Birth(mm/dd/yyyy)

  

  Gender

  

  Address

  

  City

  

  State

  

  Zip

  

Emergency Contact Information

  Contact Name

  

  Daytime Phone

  

  Evening Phone

  

  Cell Phone

  

  Secondary Contact

  

  Address

  

  Relationship to Camper

  

  Phone

  

  Tshirt Size   

Medical Information

  Immunizations Current?

 

  If NO, please explain.

 

  Medications Currently Taking

 

  • Any Prescription Medications listed above must be checked in at the First Aid Station upon arrival per state law.
  • Medications must be in their original pharmacy bottle with the physician's stated dosage or the medication cannot be legally dispensed.
  • Do Not bring Over the Counter Medication to camp- our First Aid Station is stocked with all the necessary items.

  Known Allergies

  

  Current Medical Conditions

  

  Previous Medical Conditions

  

Complete This Next Section if Currently Under Doctor's Care

  Restrictions to physical activity?   
  If YES, please explain fully:   
  Doctor's Name   
  Office Name   
  Address   
  City, Zip   
  Phone   

Authorization I

I hereby give my consent for the above named camper to travel with the sponsoring group and to take part in any and all activities involved with the camp. If I cannot be reached in the event of an emergency, I hereby give my consent for Pineywoods Camp Administration or church leadership to sign for emergency medical care should it be necessary. I understand that every effort will be made to provide the safest environment possible at camp, but that accidents can and do occur. I agree not to hold liable the sponsoring church, the camp staff, or Pineywoods in the case of an unforeseen event.

   Agree

  Parent/Guardian Name

  

Authorization II

I consent to and give permission for the use of photographs of myself /or my child taken while at camp to be used in the promotion of Pineywoods Baptist Encampment/or Over the Edge Pre-teen Camp on the Pineywoods Camp Web Page or materials.

   Agreee   Parent/Guardian Name   

Please click here to download the camp rules that must be signed by the parent/gurdian as well as the camper. Please bring this form and a $55 deposit to the church office before Friday, May 2, 2008. The deposit is nonrefundable and will be applied to your $170 total, that will be due in July.