Ambush Registration

AMBUSH REGISTRATION FORM

Camper Name

Birth Date

Age

+ -

Male

Female

Address

City

State

Zip Code

Parent/Guardian

Primary Phone

Secondary Phone

Email Address

Home Church

City

State

Cabin-Mate

Michigan state regulations require the name of the person(s) to whom we may release your child. Please release my child to:

1.)

2.)

In case of emergency, the camper’s personal health insurance will be used before Camp Selah’s coverage.

Insurance Company

Policy Number

Phone

HEALTH INFORMATION

Date of Last Tetanus Shot

Allergies (Check all that apply)

Bee Stings

Poison Ivy-severe reaction

Other Allergies (Please List)

Medicinal Allergies (Please List)

Food Allergies* (Please List)

List All Allergies *INCLUDING ALL FOOD ALERGIES*

Health History (Check all that apply)

Heart Trouble

Seizures

Asthma

Headaches-mild

Diabetes

Migraines

Sleepwalking

Bedwetting

Emotional or Behavioral Disorders

Other health and/or behavioral considerations

Current Medications

All medications brought to camp must be in their ORIGINAL CONTAINERS with dosage/frequency labeled accordingly.

PARENTAL AGREEMENT

“I hereby certify that the above information is correct, and give permission for the use of photographs or videos including my child to be used in camp publicity, and for the release of medical records in case of illness or injury. In the event that my child's emergency contact cannot be reached, I hereby give permission to the physician selected by Camp Selah to give emergency medical or surgical treatment and routine non-surgical medical care to my child.” PARENT/GUARDIAN ELECTRONIC SIGNATURE

Date

Our Privacy Policy applies.

Note: Please fill out the fields marked with an asterisk.