Camp Bethany

Registration, Medical Release & Emergency Information

Name:__________________________________________________________________________________

Address: _______________________________________________________________________________

City, State & Zip:_________________________________________________________________________

Home Phone: ____________________________Parent's Work Phone:______________________________

Email Address: __________________________________________________________________________

Birth Date: _________________________ Age: _________  School Grade Completed ________________

Circle Gender:     Male   Female       Circle Qualification: Student      Adult Leader       Youth Pastor

Shirt Size _____________   Church Member? Y   N   Church Name ________________________________

In the event that ____________________ becomes ill or sustains an injury while participating in or traveling to or from an authorized and chaperoned youth event at Camp Bethany in Bethany, Louisiana. I, the undersigned, give my permission to those in charge to take whatever steps are necessary to stop any bleeding and/or administer first aid. I also consent to X-Ray examinations, Anesthetic, Medical, Dental, or Surgical diagnosis and treatment, including invasive procedures and hospital care as well as the administration of drugs or medicine to be rendered to my son, daughter or child under my legal watch care, under the general or specialized supervision and upon the advice of a duly licensed physician and/or surgeon. I understand that this consent will apply to all emergency situations present and future and will remain in effect until written revocation is received by certified United States Mail. I also agree that Camp Bethany, the Northwest Louisiana Baptist Association, its staff and/or volunteers will not be held responsible for any physical or emotional injuries received while participating in events and travel associated with Camp Bethany and the Northwest Louisiana Baptist Association. I assume all responsibility for any medical and emergency expenses associated with any accident , injury, or other incapacity, regardless of whether I have authorized such expenses.

___________________________________                        ___________________

Signature of Parent / Guardian                                                                             Date

Insurance Policy Number __________________________________________________________________

Group Policy Number _____________________________________________________________________

Group Policy with ________________________________________________________________________

Coverage Verification Phone Number_________________________________________________________

List any medical, physical, or other limitations_______________________________________________________________________________

Allergies_________________________________________________________________________________

Last Tetanus Shot _______________________________________________________________________

Current Medications_______________________________________________________________________

Doctor’s Name ____________________________________________________ Phone _________________