BANNOCK CIVITAN
CAMP TAYLOR CAMPOUT
REGISTRATION AND
MEDICAL INFORMATION & RELEASE FORM
***Meet at New Day for pick up - Fri June 3, 2016 at 3:00 pm
****Return to New Day - Sun. June 5 , 2016 at noon
RETURN REGISTRATION AND MEDICAL RELEASE FORM WITH $10.00
TO:
Adult Living NEW DAY PRODUCTS
OR
MAIL TO:
Ann Mc Carty 8009 North Neva Road POCATELLO, ID 83204 if you have any question please call me Ann Mc Carty @208-244-1402
BY Friday, May 27, 2016
Camper Name______Age:_____ DOB:______
Parent/Guardian Name(s) ______
Telephone number ______
Address______
City______State: ______Zip:______
(C)______Other ______
Shirt Size
MEDICAL INFORMATION AND RELEASE:
WILL CAMPER BE TAKING ANY MEDICATION? Yes ______No ______
1. Campers must be able to take their own medication.
2. All medication should be in the original prescription package with camper’s name, drug name/strength and dosing information clearly legible.
Name Dosage
DOES CAMPER HAVE ANY ALLERGIES? Yes ______No ______
If yes please explain: ______
______
Emergency Contact if unable to reach parent/guardian:
Name______(#) ______
Relationship to camper______
Authorization for Emergency Treatment
Should emergency medical care be needed for any camper, camp personnel will accompany them to the local health care facility. Hospitals require that camp have authorization to act on your behalf to sign their “Authorization for Emergency Treatment” form. By signing below you give Bannock Civitan Camp Staff permission to act on your behalf, should emergency care be needed.
I hereby give consent and permission for Bannock Civitan to authorize emergency treatment for:
______(Camper’s Name)
Parent/guardian Signature______Date: ______
Camper’s Physician______
INSTRUCTIONS:
1. CAMPER NEEDS TO BRING OWN SLEEPING BAG/PILLOWS/BLANKETS.
2. CAMPER MUST FURNISH OWN PERSONAL ITEMS; TOOTHBRUSH, SOAP, ETC.
PLEASE PACK PERSONAL ITEMS IN SMALL SUITCASE OR BAG.
3. MEALS WILL BE PROVIDED
Friday Night Dinner, Smores
Saturday, Breakfast, Lunch and Dinner, and SNACKS.
Sunday, Breakfast
Return to New Day Products at noon
*** Dress for the Weather****