Camper's Name* First Last Home ChurchCabin Mate 1 First Last Cabin Mate 2 First Last Age*Birthdate* MM slash DD slash YYYY Current Grade*6789101112Gender* Male FemaleT Shirt Size*SmallMediumLargeX LargeAddress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent/Guardian*Email Home PhoneCell PhoneEmergency Contact*Emergency Contact Phone*Physician's NamePhysician's PhoneInsurance Carrier*Insurance PhoneInsurance Carrier's Health Card #*Insurance Group #*Does the camper have any medical restrictions?* Yes NoMedical Restrictions DetailsIf yes, Please explain:Does the camper have any activity restrictions?* Yes NoActivity Restrictions DetailsIf yes, Please explain:Is the camper under medical treatment?* Yes NoMedical Treatment DetailsIf yes, Please explain:Medical HistoryPlease select any medical history Sore Throats Fainting Kidney Trouble Convulsions Dietary Restrictions Sinusitis Upset Stomach Asthma Sleepwalking Bronchitis Diabetes Bedwetting Heart troublePlease explain any medical history:Please select any known allergies Drugs Food Plants Animals Bee Stings OtherPlease provide details of any known allergies:Antidote Selection Nurse Administered Self CareDate of last Tetanus shot MM slash DD slash YYYY OTC Drug AdministrationPlease select any or all of the following over the counter medicines that you allow the nurse to administer" Tylenol Tums Pepto Bismol Benadryl Imodium Cough Drops Sudafed PE IbuprofenOTC Other MedsPlease detail any other Over the Counter medicines that you allow the nurse to administer:Is the camper currently taking medications?* Yes NoCurrent MedsPlease detail any medications that your child is currently taking, the dosage, how many times per day it should be taken, how many pills you will be sending, and how many pills should come home.MedicationDosageTimes# of pills on arrival# of pills sent home Medical Consent*By selecting yes, you are agreeing that to the best of your knowledge, this Health History is accurate. You are in favor of and grant permission for the child on this form to attend camp and participate in all activities unless other wise specified. As parent/guardian, you accept the conditions stated including the release of Presbytery of the Ascension, the camp director, and the camp nurse from any liability, lawsuits, demands, expenses, or costs arising out of the administration of or failure to administer first aid or emergency treatment to your child in the case of injury or illness. As parent/guardian, you verify that the child listed on this form is insured and you grant permission to the camp director, his designate, and/or any medical personnel selected by the camp director to render whatever emergency medical treatment may be judged necessary to your child. Yes NoMedical Consent Signature*Photo Consent*I hereby grant to the Ascension Presbytery the absolute and irrevocable right and unrestricted permission in respect of photographic portraits, or any pictures the Ascension Presbytery had taken of me or in which I may be included with others, editorial or any other media such as film or video, to copyright the same; to reuse, publish and republish the same in whole or in part, individually or in conjunction with other photographs, and in conjunction with any printed matter, in any and all media now or hereafter known, including web pages and social networking media, and for any other purpose whatsoever, for illustration, promotion, art, editorial, advertising and trade, or any other purpose whatsoever with restriction as to alteration; from time to time, or reproductions thereof in color, black and white or otherwise made through any media. I hereby waive any right that I may have to inspect or approve the finished products or the advertising copy or printed matter that may be used in connection therewith or the use to which it may be applied. I hereby release, discharge and agree to save harmless Ascension Presbytery, its legal representatives or assigns and all persons acting under its permission or authority, from any liability in connection with the use of the photographs, video and/or film as aforesaid or by virtue of any alteration, processing or use thereof in composite form, whether intentional or otherwise, as well as any publication thereof. I understand that the photographs, video and/or film taken by Ascension Presbytery will be included into stock files. I agree that the photographs, the transparencies thereof, video and/or film, and the rights to copyright the same, shall be the sole property of Ascension Presbytery, with full right of lawful disposition in any manner. I hereby grant permission to Ascension Presbytery to photograph Ascension Presbytery participant during activities and to use the photographs, video and/or film in Ascension Presbytery audio-visual and printed materials without compensation or approval rights. Yes NoPhoneThis field is for validation purposes and should be left unchanged.