Tristate Registration

TRI-STATE REGISTRATION FORM

Camper Name

Birth Date

Age

+ -

Male

Female

T-Shirt Size (Standard Unisex Adult Sizes)

Youth Medium

Small

Medium

Large

X-Large

XX-Large

XXX-Large

Address

City

State

Zip Code

Primary Phone

Email Address

Emergency Contact

Emergency Contact Phone

Church

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

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

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

CAMPER AGREEMENT

“I hereby certify that the above information is correct, and give permission for the use of photographs or videos including myself to be used in camp publicity, and for the release of medical records in case of illness or injury. In the event that my 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.” CAMPER ELECTRONIC SIGNATURE

Date

Our Privacy Policy applies.

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