Ignition Summer Camp

Camper Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent 1 Name *

First Name

Last Name

Parent 1 Phone *

(###)

###

####

Parent 2 Name

First Name

Last Name

Parent 2 Phone

(###)

###

####

Physician Phone

(###)

###

####

Is your child being treated for an injury or sickness, taking medications, or have any allergies we should know about? *

Yes

No

Does your child require a special diet? *

We will do our best to accommodate dietary restrictions, contact Mikey to discuss meals.

Yes

No

Medical Release *

By checking the box below, I understand that I will be notified in the case of a medical emergency involving my child. However, in the event that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child may become injured or ill. I understand that Mid Valley Baptist Church or Ingalls Creek Enrichment Center will not be responsible for medical expenses incurred solely on this authorization. I, the undersigned, being the parent or legal guardian of the child named above, do hereby consent to the participation of my child in all regularly scheduled activities of camp. Further, I certify that my child is physically fit and able to participate in such events (except as noted above).

I agree

Today's Date *

MM

DD

YYYY

Transportation Release *

By checking the box below, I give permission for my child to ride in any church vehicle or chaperone driven personal vehicle off camp premises to Lake Wenatchee State Park.

I agree

Today's Date *

MM

DD

YYYY