Address:

City: State:
Zip/Postal Code:

E-mail address:

Responsible Person (for children 8 years and under
website address:

Tell me about yourself:
Male Female
Age: (September 1, 2006)

Health Problems. Please check
Heart Asthma Fainting Nosebleed Ears Emotional

Allergies
Food Insects Penicillin Other Med. Other

Immunization Dates
Polio Mumps Measles Rubella DPT and/or TD

Is the camper able to participate in all activities? Yes No
If not, explain (please be specific):

Please list any other medical condition that we need to be aware of:

Permission to administer: Aspirin? Yes Tylenol? Yes Ibuprofin? Yes Benadryl? Yes

Medications: List all medications camper is taking:

ALL PRESCRIPTIONS & MEDICATIONS ARE TO BE GIVEN BY THE CAMP NURSE OR A PARENT STAYING AT CAMP.

Please send all medications your child will need at camp in their original containers.

Insurance Information:(if applicable)
Policy #
Group #
Name of Insured

Medical Emergency Authorization Agreement
Must be signed for all campers under 18 years of age.

" (Camper's Name) has my permission to engage in prescribed activities, except as noted by me above. In the event I cannot be reasched in an emergency, I hereby give permission to the physician selected by an adult leader in charge, to order injection, surgery, or any other medical treatment that may be deemed necessary to ensure the well-being of the above named camper, due to sickness or accident while attending camp at Camp Arrowhead, or en route to or from the Camp. I also authorize the camp personnel or an adult leader to transport my child at their discretion in case of an emergency."

"We represent to you that we and the participant hold Camp Arrowhead, its agents, employees and representatives harmless from all liability arising as a result of the conduct of the participant and agree to defend and indemnify Camp Arrowhead, it agents, employees, and representatives against any claim or liability as a result of such conduct."

Parent's (or Guardian's Signature) Date:

Rules Agreement:must be signed by all those ages 9 and up)

"I have read and agree abide by Camp Arrowhead rules given below."

Camper's Signature Date

Thank You