2013                                                   2812 North River Rd

Address ______________________________________________         Age _____ Grade _______

City/ State/ Zip _________________________________________         Male ___ Female _______

Home Phone ______________________   E-Mail  _______________________________________

Home Church   ___________________________________________________________________

Cabinmate Request  _______________________________________________________________

Parents Name(s)   _________________________________________________________________

Camp Attending  __________________________________________________________________

Medical Release ( for campers under age 18 )

Emergency Contact Name _____________________________________ Phone #  ____________

Insurance Company  ______________________________________________________________

Policy # _____________________________________ Doctor _____________________________

Allergies/ Reactions _______________________________________________________________

   ______________________________________________________________________________

Activity/ Diet Restrictions ___________________________________________________________

Current Medications _______________________________________________________________

Lice Checks will be administered at registration. Positive Checks will be SENT HOME.

• I understand that I must give permission before my child receives any over-the-counter medications.
• All medication will be turned in to Nurse during check-in. ( Shiloh only offers first-aid. No registered Nurse on staff.)
• In case of medical emergency for my child, I authorize Shiloh Bible Camp staff to act in their best judgment to seek medical attention through the appropriate means, including ambulance transport and emergency room treatment. I also accept responsibility for the expenses incurred through such treatments.
• My child has permission to participate in all activities on or off the grounds.
• I give permission to Shiloh Bible Camp to use photos or video of my family in publications. I release my right to any kind of remuneration for said photos or video.

_________________________________________________________________________________________________

^{Signature                                                                                                                                                                  Relation                                                                        Date}