2024 Camper Registration Form

Camper Information

Camper Name:

Email Address: (for registration confirmation & payment receipt

This address will receive a confirmation email

Birthdate: (xx/xx/xxxx)

Gender:

Female Male

Grade Completed: (as of June 2024)

1st 2nd 3rd 4th 5th 6th

Church Affiliation:

T-Shirt Size:

Youth S Youth M Youth L Youth XL Adult S Adult M Adult L Adult XL

Parent or Guardian Information

Parent or Guardian's Name:

Mailing Address:

Cell Phone: (or best contact number)

Email Address: (if different from above)

Track Choices (Please choose your tracks in order of preference.)

Insurance and Health Information

Health Insurance Company:

Group #:

Policy #:

Allergies: (please list)

Medical Conditions: (please list)

Current Medications: (please list)

Other Special Needs: (please list)

Emergency Medical Contact: (please list names and contact numbers)

I understand that photographs or videos may be taken of the Camper and used in promotional materials.

Yes No

By digitally submitting this form, I grant my permission for the Camp Director, Assistant Director or other Staff members in charge to obtain necessary medical treatment in case of sickness or injury to the Camper named above. I do hereby release and forever discharge all sponsors, Middle Florida Baptist Assembly, Inc. (dba Pickett Lake Camp) and the event named above from any and all claims, demands, actions or cause of action past, present or future arising out of any damage or injury while participating in the event during the dates listed above. I hereby also agree to assume obligation for any necessary expense not covered by Middle Florida Baptist Assembly, Inc.'s insurance policy on the Camper named above.

Yes No

Payment:

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

2024 Camper Registration Form

Description

Please Fix the Following