General Information

Parent Email

Camper First Name

Camper Middle Name

Camper Last Name

Address

Birthday

Month

Day

Year

Age

Sex

Male

Female

Grade (In Fall)

Week of Camp

Parent/Guardian Name

Parent/Guardian Number

Camper Medical Report

Is there any necessary information we should know about your camper's allergies?

Current Medications (Name and Dosage)

Does Epic Ministries have parent/guardian permission to administer over the counter medication?

Yes

No

Insurance Information

Insurance Company Name

Member I.D Number

Group I.D

Name of Camper's Physician/Physician's Office

Parent/Guardian Information

Parent/Guardian 1 Name

Parent/Guardian 1 Number

Parents/Guardian 2 Name

Parent/Guardian 2 Number

If we are unable to contact the parents/guardians, we ask that you provide another contact. This person will not be contact unless there is an emergency and both primary contacts can not be contacted.

Emergency Contact Name

Emergency Contact Number

Disclaimer Section

In the event that I cannot be reached in an emergency, I hereby grant permission to the medical personnel selected by the camp director to hospitalize, order X-Rays, injection and/or surgery, routine tests and secure proper treatment for my child as named above. I also grant permission to medical personnel to obtain access to necessary medical, psychiatric, or social work records.

Signature

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I understand that camp activities may involve some risk of injury. By allowing my child to attend Epic Youth Camp, I release Epic Ministries Association and Doorkeepers Christian Outreach, their staff, and volunteers from responsibility for any accidents or injuries that may happen during camp activities.

I also give permission for the camp to get medical help for my child if needed, and I agree to cover any related costs.

Signature

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I hereby grant Epic Ministries and "Epic Youth Camp" the right to use and distribute photos that may be taken of my child during camp to use in brochures, flyers, etc.

Signature

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Additional Information

Please note any other information you think Epic Youth Camp staff should be aware of.

If you have a request for a roommate, please list them below.