Camper
N ame:
_ ___________________________________________Birthdate:__________________________
5.
Has
y our
c hild
e ver
h ad:
Seizures_____
Asthma______
D iabetes_______
Heart
d isease______
O ther_______________________________
6.
Date
o f
l ast
t etanus
s hot:_____________
Please
s ign
O NLY
O NE
o f
t he
f ollowing
s tatements
r egarding
i nsurance:
1.) I
h ereby
g ive
m y
c onsent
t o
a ny
e mergency
m edical
t reatment
n ecessary
f or
m y
c hild
r esulting
f rom
a n
accident
o r
i llness.
I
a ccept
f inancial
r esponsibility
a nd
u nderstand
t hat
m y
i nsurance
w ill
b e
b illed
b efore
Brotherhood
M utual,
w hich
i s
t he
c arrier
f or
C amp
B eaverfork.
Parent/Guardian
S ignature____________________________________________
2.) I
h ereby
g ive
m y
c onsent
t o
a ny
e mergency
m edical
t reatment
n ecessary
f or
m y
c hild
r esulting
f rom
a n
accident
o r
i llness.
I
c ertify
t hat
n either
I
n or
m y
f amily
h as
a ny
t ype
o f
h ealth
i nsurance
c overage.
Parent/Guardian
S ignature_____________________________________________
Date
o f
C amp
W eek
A ttending__________________________________________
CAMP
B EAVERFORK
N O
L ONGER
H AS
P RIMARY
P AY
I NSURANCE.
W E
C ARRY
S ECONDARY,
W HICH
MAKES
T HE
C OMPLETION
O F
T HIS
F ORM
A N
I MPERITIVE.
__________________________________________________________________________________________
Please
r ead
a nd
s ign
t he
b elow
W aiver
o f
L iability
A greement:
1) We,
( I)
o n
b ehalf
o f
m y
c hild-‐participant
d o
h ereby
r elease,
f orever
d ischarge
a nd
a gree
t o
h old
h armless
C amp
Beaverfork
/
A rkansas
F ree
W ill
B aptist,
I nc.
a nd
t he
d irectors
t hereof
f rom
a ny
a nd
a ll
l iability,
c laims
o r
d emands
f or
personal
i njury,
s ickness
o r
d eath,
a s
w ell
a s
p roperty
d amage
a nd
e xpenses,
o f
a ny
n ature
w hatsoever
w hich
m ay
b e
incurred
b y
t he
u ndersigned
a nd
t he
c hild-‐participant
t hat
o ccur
w hile
s aid
c hild
i s
p articipating
a t
S ummer
c amp.
2) I
g ive
p ermission
f or
a ll
p ictures
a nd
v ideo
t aken
d uring
t he
w eek
o f
c amp
t o
b e
u sed
b y
C amp
B eaverfork
i n
a ny
m edia
format
i ncluding
b ut
n ot
l imited
t o
p rint,
v ideo,
s ocial
m edia
a nd
w eb
f or
C amp
B eaverfork
a nd
o ther
p ublishing
u sed
by
A rkansas
F ree
W ill
B aptist,
I nc,
Parent/Guardian
S ignature_____________________________________________
Date____________________