Silica Bible Chapel
Sacramento, California
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PRAYER
Pray for David Hanson
Camp Hope
About
2023 Theme
Location
Registration
Camp Hope Medical Form
Emergency Information:
*
Indicates required field
Child's Name
*
First
Last
Child's Date of Birth:
*
Parent or Guardians name
*
First
Last
Day Phone Number
*
Evening Phone Number
*
Alternate Emergency Contact
*
First
Last
Alternate Day Number
*
Alternate Evening Number
*
IN CASE OF A MEDICAL EMERGENCY
, I understand that every effort will be made to contact a responsible parent or guardian of the camper. In the event that contact cannot be made, I hereby give permission to a camp director and the physician they may select to secure proper treatment for, to hospitalize, and to order such injections, anesthesia or operations as may be urgently necessary for this child. In the event of a claim, family insurance (if any) may be liable. By checking this box, I agree to every condition listed above, and certify that all the above information I provided is accurate to the best of my knowledge:
Parent/Guardian Consent
*
I agree
I do not agree
Name
*
First
Last
Date
*
Campers Health Information:
To the best of my knowledge, this child is healthy and fit for an active camp program:
*
Yes
No
If No, you must explain why below
If No, please explain:
*
Immunizations: Are they current and up to date?
*
Yes
No
Date of last Tetanas shot:
*
Regular Medications:
*
All prescriptions and over the counter medications must be clearly labeled in the original container and turned in to the Camp nurse.
Are there any Activity Restrictions for your child?
*
This child is currently experiencing or has recently had problems with:
*
ADD/ADHD
Allergies
Asthma/Inhaler
Bed Wetting
Bee Stings
Medicines
Penicillin
Restricted Diet
Sleep Walking
None of the Above
Others (Please specify below)
Other Problems:
*
If my child uses an inhaler, he/she may keep the inhaler to use as needed:
*
Yes
No
I understand that standard over the counter medications may be used for common symptoms and have listed above any that should be avoided. I authorize Camp Hope’s Health Supervisor or other representative to dispense prescription and over the counter medication as needed.
By checking this box, I agree to every condition listed above, and certify that all the above information I provided is accurate to the best of my knowledge:
Parent/Guardian Consent
*
I agree
I do not agree
Name
*
First
Last
Date
*
Consent:
I hereby give permission for the above child to attend Camp Hope sponsored by the Silica Bible Chapel and to participate in all activities. I will not hold the Silica Bible Chapel or its agents liable for injury caused by common accident, illness or the rendering, or emergency care. I give permission for this child to participate in any off-site activities during camp and to be transported to and from any off-site activities, including emergency situations (if any) by authorized vehicles. By checking this box, I agree to every condition listed above, and certify that all the above information I provided is accurate to the best of my knowledge:
Parent/Guardian Consent
*
I agree
I do not agree
Name
*
First
Last
Date
*
Submit