Brookside Baptist Church
Tuesday, October 21, 2014

Text Box: Kamper Name ________________________________________________	________________________________________________
Last										First
Church ________________________________________________________	Cabin _________________________________
Registration Form 2014

Kids Mission Adventure Kamp

    KMAK 5—July 14-17    

(T-shirt size Circle One)

Youth:  Y-Med  Y-Large     Adult size:   S     M      L     XL      XXL     XXXL

                                               

 Name of person attending camp: 

School Grade Completed Sex (check one)  F  Age   Birth date

Sponsoring Church: Brookside Baptist Church

Parent or Guardian (of minor )Home Phone  _____________

Address___________________________________ City___________________ St______ Zip________

e-mail address _______________________________________________________________________

In case of emergency notify: ______________________________ Relationship__________________

Emergency phone numbers: Day_________________ Night______________ Cell __________________

Physician’s Name_____________________ (Imperative if your child has allergies.) Phone____________

List any allergies to medications or any known allergies________________________________________

____________________________________________________________________________________

Date of last tetanus immunization________________ List medications presently being taken: ____________________________________________________________________________________

____________________________________________________________________________________

Medical Insurance Company__________________________ Insurance Policy #___________________

(This above information is needed in case your child or the sponsor has to taken to the hospital and the

parent/guardian cannot be reached.)__________________________________ Date________________

                                                            Signature of Parent /Guardian/Sponsor

AUTHORIZATION FOR EMERGENCY CARE TO A MINOR

I/we the undersigned, parent(s) or legal guardian of the minor (name)_____________________________

(birthday)________________, do hereby authorize any X-ray examination, anesthetic, dental, medical, or surgical diagnosis or treatment by any physician or dentist licensed by the State of Oklahoma and hospital service that may be rendered to said minor under the general, specific or special consent of: ______________________________________

(Name of adult sponsor who is temporary custodian of minor)

It is understood that this consent is given in advance of any specific diagnosis or treatment being required,   but is given to encourage those persons who have temporary custody of the minor, and said physician or dentist to exercise his/their best judgment as to the requirements of such diagnosis or medical or dental or surgical treatment.

 Date________________ Parent /Legal Guardian____________________________________________

 

AUTHORIZATION FOR MEDICAL INFORMATION RELEASE

I hereby authorize the hospital to release the following information contained in its hospital records to the representative of the Tulsa Metro Baptist Association concerning Diagnosis, prognosis for

_____________________________________________________ Date of birth ____________________

            Name of Camper/Sponsor

This information will be used for insurance billing.  ________________________________ Date _______                                                                                        Signature of Parent or Guardian/Sponsor

     KMAK

PARENTAL AUTHORIZATION TO

ADMINISTER MEDICATION

This medication form must accompany ALL medication to be given at KMAK.  All medications MUST be given to the Camp First Aid person at the time of arrival in the original container, whether it is a prescription or over the counter medication.

I hereby give my permission to the Camp First Aid person and to designated camp staff to administer medication to my child at KMAK.

 

Name of Child ________________________________________________________________Age:  ___________ Weight:  _____________

 

Church name:____________________________________________________________ City:_____________________________________

 

I understand that the camp first aid person and/or the KMAK staff shall not be liable to the student, parent, or

guardian of the child for civil damages for any personal injuries to the student, which result from acts or omissions

in administering any medication at KMAK.

 

_______________________________________________                  _________________________

Signature of Parent or Legal Guardian                                                            Date

 

 
 
 MEDICATION MUST BE BROUGHT IN THE ORIGINAL CONTAINER
 

 


 

Name of medication(s):____________________________________________________________

 ______________________________________________________________________________

Reason for medication to be given and/or comments: ____________________________________

 

Time(s) to administer medication at camp: ____________________________________________

 _____________________________________________________________________________

Dates to administer medication at camp: ______________________________________________

Side effects to be reported to parents: ________________________________________________

______________________________________________________________________________

 

Side effects requiring immediate medical attention: ______________________________________

 

List of medications:

 1)___________________________________________________________________________

2)___________________________________________________________________________

 

3)___________________________________________________________________________

 

4)___________________________________________________________________________

                                                        A.M. Breakfast                    Noon Lunch                         P.M. Dinner                                           Bed Time

 

Monday

 

 

 

 

 

Tuesday

 

 

 

 

 

Wednesday

 

 

 

 

 

Thursday

 

 

 

 

 

 

Notes from first aid person: __________________________________________________________________________________________________________________

 

___________________________________________________________________________________________________________________

 Submit Form