KBK - Katepwa Baptist Kamp

Hospitalization #:

Doctor:

Doctor's Phone:

Parents/Guardian(s):

Parents/Guardian(s) Phone #’s:

Emergency Contact:

Emergency Contact Phone #:

Please list all medication requirements, allergies, conditions or health concerns our medical officer & staff should be aware of:

Please review the following list of medications and check the MEDICATIONS YOU WILL NOT PERMIT the nurse to administer:

I hereby authorize the KBK medical officer to provide or secure medical services as may be deemed necessary for my child's health and safety. I will be informed immediately of any medical services that are required. I release Katepwa Baptist kamp Inc. and anyone connected with it from any or all liability claims resulting from accident and/or misfortune. I understand that my child's image or likeness may be used in kamp activites or promotional material eg. cabin skits, calendars, websites, etc.
I agree	I do not agree
Note: Should this not be acceptable, please contact KBK Program Director in writing before Kamp begins.

	Skamper Kamp (Age: 6 – 8, Date: July 23-25) ($100.00)
	Junior 1 Kamp (Age: 8 – 12, Date: July 4-9) ($225.00)
	Junior 2 Kamp (Age: 8 – 12, Date: July 18-23) ($225.00)
	Junior 3 Kamp (Age: 8 – 12, Date: August 8-13) ($225.00)
	Junior Teen 1 Kamp (Age: 12 – 14, Date: July 11-16) ($240.00)
	Junior Teen 2 Kamp (Age: 12 – 14, Date: August 1-6) ($240.00)
	Senior Teen Kamp (Age: 14 - 18, Date: August 15-20) ($240.00)
	Paintball (optional; Sr. and Jr. Teen Kamps only) ($10.00)
	Extreme Kamp (Age: 14 - 18, Date: July 18-22) ($225.00)
	Extreme Kamp (Age: 14 - 18, Date: August 8-12) ($225.00)
	T-shirt (email your size to the office: S M L XL) ($15.00)
	Staff Training Kamp (Age: 16+, Date: June 26-July 1) ($0.00)

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