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Please complete and return with your paymentq I will obey what the leadership instructs or requests Paid: ________ Ck#: _________ Date: ________ q I will pay necessary costs to cover any damage to property Paid: ________ Ck#: _________ Date: ________ q I understand the $25 penalty for any “prank” I cause or do Paid: ________ Ck#: _________ Date: ________ Name: _______________________________ Address: ____________________________________________City/State/Zip _________________________Phone ________________ Cell ___________________________Email ________________________ q Boy q Girl Completed Grade ___ Date Of Birth __ / ____ / ____T- shirt size: q Youth M q Youth L q Adult S q Adult M q Adult L School _______________________ q I DO NOT give permission for my child to ride in and tube behind a boat.
I give permission for my child to be given the following medications if needed. Please check the box beside the medicine:q Pepto Bismol q Dimetap q Ibuprofen q Tylenol q Tums q Benadryl q ClaritinMEDICAL ALLERGIES: _______________________________________________________________________FOOD ALLERGIES: __________________________________________________________________________ q My child takes the following prescription medication(s): __________________________________________ Date of last Tetanus: ________ Insurance Co: _____________________ Policy#: _______________________If you do not have insurance please fill out the following:Name of person responsible for any medical cost incurred at camp: __________________________________Address: ______________________________________________ SS #: _______________________________ I hereby give my permission for my above named child to attend this activity as wel as to ride the bus to and from Lake Placid Camp and Conference Center for al included camp activities. I further hereby release and hold harmless Lake Placid Camp and Conference Center, First Baptist Church of West Palm Beach, any leader or worker for any injury and/or il ness sustained by my child as a result of his/her participation in these related activities, regardless of the cause of such il ness or injury. Further, I hereby give consent to administer prescribed medications and any necessary treatment to my above-named child in the event of an emergency in the event I cannot be reached. I further give my consent to transport my child by ambulance if the situation so war- rants. I understand that the ambulance wil be at my expense.
I hereby confer on First Baptist Church of West Palm Beach permission to take photographs of my child in which he/she may be included with others. Further, I give First Baptist Church of West Palm Beach permission to use, re-use, publish and re-publish the photographs in whole or in part, separately or in conjunction with other photographs, in any medium now or hereafter known, and for any purpose in- cluding but not limited to il ustration, promotion and advertising. I hereby release and discharge First Baptist Church of West Palm Beach from al and any claims in connection with the use of the photographs.
I have read the foregoing and ful y understand the contents hereof. I represent that I am the parent/guardian of the above named child and I hereby consent to the foregoing on his/her behalf.
Parent/Guardian Signature: _____________________________________Date: _______________________________________________ Please complete and return with your payment. www.FBCWPB.org • 1101 South Flagler Drive • West Palm Beach, FL 33401

Source: http://gofamilychurch.org/kidscamp/wp-content/uploads/2013/02/Camp2013.pdf