EMBC IMPACTING Registration Form

Camper Name: Last______First______

Gender: □ Male □ Female

Grade beginning in Fall 2015: ______

Mailing Address:______

City______State______Zip______

Parents or Responsible Party’s Name(s)

______

Mailing Address______

(If different from camper’s)

City______State______Zip______

Home Phone______Work Phone______

Other Phone______

Email______

Name of Church______

City______Pastor/Clergy's Name______

If possible I would like to be in the same cabin as:

1)______2)______

I give my permission for ______to attend IMPACTING at EMBC and for any pictures/video taken to be used for promotional material, including online.

______

Signature of parent or guardian

Registration Fee: $30 if postmarked by Oct. 8th. After Oct. 8th, please pay $40 on the day of the event. One day registration is also available for $20. Please indicate which day you plan to attend: Thursday ______Friday ______

Please return Completed Forms and make checks payable to:

Eastern Montana Bible Camp

1862 Rd 523

BloomfieldMT59315
EASTERN MONTANA BIBLE CAMP HEALTH AGREEMENT

Family Physician ______Address______Phone______

Your Insurance Carrier Policy/Group # ______

How may you be contacted in case of an emergency? ______

Person to contact if family can't be contacted______Phone ______

Person(s) other than named above, to whom the camp may release the child upon request. ______

Do you have any known allergic reactions (include food, medicine, plants, insects)? ______

Do you have any illnesses requiring medication?______Medication______Dosage______Prescribed by ______Medication______Dosage ______Prescribed by ______

*All medicines must be sent with the camper and be reported and checked in with the camp*

*If your child is taking behavior modification medicine, please continue medication through camp*

What kinds of situations might cause your child distress? ______

Does your child wear Medic-Alert Tags? Yes_____ No______Where? ______

Is your child subject to: (Answer yes or no) ______Abdominal Pain ______Ear or Sinus Trouble ______Heart Trouble ______Asthma ______Epilepsy ______Nose Bleeds ______Bedwetting ______Fainting Spells ______Sleep Walking ______Cramps ______Hay Fever ______Tonsillitis_____Diabetes______Headaches_____ Other ______

Describe child's reactions or other information we should know (e.g.Disabilities):______

Date of your last tetanus shot? ______

List any chronic illness or other condition for which your child needs treatment. (Explain - This is for a physician who might need to treat your child in case of illness or injury or for the insurance company.) ______

Authorization I______being the parent or legal guardian of ______affirm that this form is complete and accurate to my knowledge and grant permission for her/him to participate at Eastern Montana Bible Camp. I will not hold the sponsoring organization or host facility or their representatives responsible in case of an accident. I give permission for the CampNurse to administer simple medications such as aspirin, Tylenol, Pepto Bismal, cough syrup, etc., to my child. In case of a medical emergency, if I cannot be reached, I give permission for the director of the Camp to contact a physician. If I cannot be reached, I give permission for the attending physician to treat her/him in an emergency situation.

I AGREE TO THE TERMS ABOVE:

______

Signature of Parent or GuardianDate

______

Mailing Address, City, ZipWork Telephone