Youth Camp Registration
First Name: (*)
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Last Name: (*)
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Address: (*)
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City:
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State:
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Zip Code: (*)
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Email: (*)
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Home Phone: (*)
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Cell Phone:
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Gender: (*)
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Birthdate: (*)
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Last Grade Completed:
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Parent/Legal Guardian: (*)
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Home Phone: (*)
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Work Phone:
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Friend/Next of Kin:
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Home Phone:
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Work Phone:
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Are you allergic to any foods, latex, medications, etc.? (*)
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If Yes, Explain:
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Are you presently under a physician's care for any acute/chronic medical condition? (*)
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If Yes, Explain:
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Are you currently taking any medications?
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If Yes, Explain:
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Do you have any physical or intellectual restrictions? Any emotional or medical conditions that need special attention? (*)
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If Yes, please list all mental health and/or physical conditions:
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Have you recently been exposed to a contagious disease? (*)
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If Yes, Explain:
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Family Physician:
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Phone:
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Attach a Copy of Your Insurance Card
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In consideration of the right of the registrant to participate in this activity, I hereby give consent to and authorize the taking of photographs or video tape in which the registrant may appear. I hereby waive all rights of privacy in and to any said picture or tape. I also give permission to seek medical attention on my behalf if registrant is in need
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