Salem Alliance Church

Camper Information

Camper's First Name:     Last Name:                                 
                     Address:  

                            City:     State:     Zip:   

Parent's Email Address:

Gender: Please SelectMaleFemale                   Grade in the Fall: Please Select1st2nd3rd4th5th6th

Transportation: Please SelectMy child will ride the bus to and from camp each dayI will transport my child to and from camp each day If you wish to transport your child to camp, you must bring them to Salem Alliance church on Monday to go through registration, lice check and meeting their group. They will need to be at the church by 7:30 am on Monday.

Buddy Preference: 
   (must be no more than one grade apart; request must be mutual)

Emergency Contact Information

    Parent/Guardian's Name:

         Home Phone Number:

            Cell Phone Number:

           Work Phone Number:

    Secondary Emergency Contact:

                   Relationship to Child:

                             Phone number:

Health Information  

Camper's Height:             Camper's Weight:                   

 Age:         Date of Birth:                       

Are their immunizations current?

    Tetanus:  Please SelectYesNo             Polio:  Please SelectYesNo

    
    Has the appendix been removed:   Please SelectYesNo     
                                                         

Is the camper subject to:

    Convulsions: Please SelectYesNo                          Asthma: Please SelectYesNo  

        Hay Fever: Please SelectYesNo                           Diabetes: Please SelectYesNo    

 
Is the camper under psychiatric care?   Please SelectYesNo
        (If yes, the doctor's signed permission will be needed to attend camp)

Health Insurance Company (if none - write "none"):

                                                         Policy Number:

Additional Information

Please list any allergies (food, drugs, animals, etc):          

        Specific health problems or dietary restrictions:          

                                        Special needs or concerns:

Please check if camper will require ASL Interpretation: 
 

EMERGENCY RELEASE STATEMENT
In case of emergency, I understand that every effort will be made to contact me. However, if I cannot be reached, I hereby give permission to the physician selected by Canyonview to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child named above.

             By checking this box, I agree to the above statement.

LIABILITY RELEASE
I agree to indemnify and hold harmless Canyonview Camp, Bible Teaching, Inc., and it's agents and employees against all liability, claims, charges, expenses and attorney fees arising out of, or connected with the use of, its facilities and horses.

              By checking this box, I agree to the above statement.

PHOTO RELEASE
            I grant permission for Canyonview Camp to use pictures of my child in future brochures and
                 advertisements.

             I do not want pictures of my child to be used in future brochures or advertisements.