Teen Camp Registration 2023

Step 1 of 2

General Information
Church Name:*
If your church is not listed here, please contact either us or your church and request that it be added. You cannot complete registration without selecting your church name.
Camper Name*
Grade Entering this September*
Street Address*
City*
State*
Zip Code*
Home Phone
Cell Phone*
Parent's Name*
Parent's Email*
Medical Information and Authorization
Gender*
- Male
- Female
Age*
Date of Birth*
Special Medications
Allergic Reactions
- Bee Stings
- Penicillin
- Other
Other Allergic Reactions*
Type of Reaction*
Treatment Given*
Physical handicaps, Disorders, or Diseases (include infectious diseases)
Restrictive Activities (include reason)
Date of last Tetanus Shot
(Optional)
Insurance Company*
Insurance Company Address
Policy Number*
Insurance Company Phone*
Medical Authorization
In case of medical emergency, I hereby give my permission to the staff member in charge to hospitalize and/or secure the services of a licensed physician, surgeon, or anesthetist in providing the necessary care for my child as named on this application. I certify that my child is in good physical condition and is able to participate in the entire camping program except for the activities listed as “restricted.” I also give permission for my child to receive Tylenol (acetaminophen), Advil (ibuprofen), Tums, and topical triple antibiotic ointment for the treatment of minor aches or injuries.

I also consent to the use of a digital signature and agree that, by typing my name and today's date below, I am confirming that the submitted information is accurate and was submitted on my own free will.
Name of Parent / Legal Guardian*
Date*

Consent and Release Form
I, the undersigned parent or guardian, hereby consent for my child,
Consent - Child's Name*
to participate in the New England Baptist Teen Camp in Plainfeld, New Hampshire, an event sponsored by
Consent - Church Name*
on
Consent - Days of Camp*
I certify that my child is able to participate in the activities of the camp week, which may include canoeing, swimming, athletic events, and the such like. If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them on the registration form. In the event an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached, I hereby authorize
Consent - Group Leader's Name*
to make emergency medical decisions for my child. If there are any activities in which I do not want my child to be involved, I have listed them on the registration form.

I understand and hereby agree to assume all of the risks which may be encountered on said activity, including activities preliminary and subsequent thereto. I do hereby agree to hold New England Baptist Teen Camp,
Consent - Church Name*
and their agents and employees harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which I now have or which may arise in the future in connection with the activity or participation in any other associated activities.

I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by law of the state of
Consent - Your State*
and that if any portion thereof is held invalid, it is agreed that the balance shall, not withstanding, continue in full and legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital.

I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release as my own free act. This is a legally binding agreement which I have read and understand. I also consent to the use of a digital signature and agree that, by typing my name and today's date below, I am confirming that the submitted information is, to the best of my knowledge, complete and accurate.
Name of Parent / Legal Guardian*
Date*
Emergency Phone*
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Teen Camp Registration 2023

Step 1 of 2

General Information

Medical Information and Authorization

Medical Authorization

Consent and Release Form