Kamper Information

First Name:
   
Last Name:
   
Address:
   
City/Town:
   
Province:
   
Postal Code:
   
Phone:
   
Email Address:
   
Home Church:


Gender:


Date of Birth: - - (DD-MM-YYYY)
       
Age: Grade:
       
T-Shirt Size:    

Medical Information

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:
Tylenol Pepto Bismol / Tums Ibuprofen (Advil)
Gravol Sinutab Polysporin
Halls After-bite Cepacol / Lozenges
Benadryl Benylin-DM / Cough Syrup Clor-Triplon
   

Release Form

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.
   

Kamp Options

Teen Camp (Grades 8-12, Date: February 3-5) ($60.00)
Junior Camp (Grades 3-7, Date: February 10-12) ($60.00)

Payment Method


Comments

 

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