July 13-17, 2009 & July 20-24, 2009 See the Video!.......High Res or Low Res.
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July 13-17, 2009 & July 20-24, 2009 See the Video!.......High Res or Low Res. |
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Each student needs to have their parent/guardian complete the following form. There are four ways to get this form. 1) You may copy the text below and paste it into your word processor 2) you may follow this link to print out a form directly from the site and then copy at your church. Use the "back" button on your web browser to return to this page. 3) Download a Word of PC file or a Works for Mac File, using the following links: 4) If you prefer a PDF file follow the link to your left. Please use one form per student. Camp Fuego at Camp Bethany Registration, Medical Release & Emergency Information Name: __________________________________________________________________________________ Address: ________________________________________________________________________________ City, State & Zip:_________________________________________________________________________ Home Phone: ____________________________Parent's Work Phone:______________________________ Email Address: __________________________________________________________________________ Birth Date: _________________________ Age: _________ School Grade Entering in Fall _____________ Circle Gender: Male Female Circle Qualification: Student Adult Leader Youth Pastor Shirt Size (Circle One) XX XL L M S In the event that ____________________ becomes ill or sustains an injury while participating in or traveling to or from an authorized and chaperoned youth event at Camp Bethany in Bethany, Louisiana. I, the undersigned, give my permission to those in charge to take whatever steps are necessary to stop any bleeding and/or administer first aid. I also consent to X-Ray examinations, Anesthetic, Medical, Dental, or Surgical diagnosis and treatment, including invasive procedures and hospital care as well as the administration of drugs or medicine to be rendered to my son, daughter or child under my legal watch care, under the general or specialized supervision and upon the advice of a duly licensed physician and/or surgeon. I understand that this consent will apply to all emergency situations present and future and will remain in effect until written revocation is received by certified United States Mail. I also agree that Camp Bethany, the Northwest Louisiana Baptist Association, its staff and/or volunteers will not be held responsible for any physical or emotional injuries received while participating in events and travel associated with Camp Bethany and the Northwest Louisiana Baptist Association. I assume all responsibility for any medical and emergency expenses associated with any accident , injury, or other incapacity, regardless of whether I have authorized such expenses. ___________________________________ ___________________ Signature of Parent / Guardian Date Insurance Policy Number __________________________________________________________________ Group Policy Number _____________________________________________________________________ Group Policy with _________________________________________________________________________ Coverage Verification Phone Number__________________________________________________________ List any medical, physical, or other limitations__________________________________________________ Allergies_________________________________________________________________________________ Last Tetanus Shot ________________________________________________________________________ Current Medications_______________________________________________________________________ Doctor’s Name __________________________________________________ Phone _________________ |
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camp fuego • 800-478-3755 • 305 market street • suite 777 • shreveport • louisiana • 71101 |