MO – OK Baptist Deaf Youth Camp Registration Fee $90.00
AGES 10 through HIGH SCHOOL
Name___________________________________________ Age_______________ Male_____ Female_______
Home Address: ____________________________________________________________________________
(Street or PO Box)
City: ________________________________________________ State: _________ Zip: __________________
Email Address: __________________________________________________ Birthday: __________________
Parent /Guardian: __________________________________________________________________________
Address:_______________________________________ City:________________ State:_____ Zip:_________
Home Phone: (______)__________________ Work Phone: (_____)______________________
Pager:____________________________________ Email: _________________________________________
Place of Employment: _______________________________________________________________________
Address of Employer:________________________________________________________________________
Family’s Religious Preference: ________________________________________________________________
Does camper use: ASL____ PSE____ SEE____ Lipread?____ Both?_____ Oral_____
Does camper use a sign language interpreter at school? Yes _______ No _______
EMERGENCY CONTACT: If Parent or Guardian cannot be located, in case of emergency call:
_____________________________________________________________ PHONE: (_____)______________
Address: _____________________________________________________ Relationship: _________________
Persons designated to take child from camp other than those above (include name, address, phone):
_________________________________________________________________________________________
Persons not permitted to take child from camp:
_________________________________________________________________________________________
Camper’s Doctor’s Name: ____________________________________________________________________
Address: ____________________________________________________ Telephone: (_____)____________
City:____________________________________________________________State:_______Zip __________
Camper’s Dentist Name: _____________________________________________________________________
Address: _____________________________________________________ Telephone: (_____)____________
City:_____________________________________________________________State:_______Zip __________
AUTHORIZATION TO PARTICIPATE IN CAMP ACTIVITIES
I hereby give permission for my child to go on field trips away from camp premises, whether on foot or by vehicle.
__________________________________________________ ______________________
Parent(s) or Guardian(s) Signature Date
__________________________________________________ _______________________
Parent(s) or Guardian(s) Signature Date
Permission to Photograph/Video
This year Deaf Youth Camp will be producing a video of our week at camp. The video will be used for camp
purposes only. We need the permission of the Parent/Guardian to take pictures of your child or youth. There will
not be any names used in this video.
MO – OK Deaf Youth Camp has my permission to video/photograph my child/youth to be used for camp
purposes/promotion only.
__________________________________________________ ________________________
Parent(s) or Guardian(s) Signature Date
Camp T-Shirt Order Form
Remember, if you turn in and have completely filled out the camp application and
camper health form by May 20, 2009 you will receive one (1) free t-shirt.
Please check your t-shirt size.
_____ Adult Small _____ Adult X-Large
_____ Adult Medium _____ Adult XX-Large
_____ Adult Large _____ Adult XXX-Large
List any sport or activity limitations that your camper may have: _________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Please share any other information that would aid your camper’s counselor in knowing your camper better.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
PLEASE READ CAREFULLY AND SIGN
PARENT’S/GUARDIAN’S AUTHORIZATION: I approve the application above and the conditions listed here and on
the CAMP HEALTH FORM, and hereby certify that my child is of good moral character. My permission is hereby
granted to use pictures of my child in camp advertising material. It is agreed that MO-OK Deaf Youth Camp will not
be held responsible for unforeseen accidents or illness of my child. I grant permission for my child to participate in
every Camp sport and activity unless listed and discussed above. I recognize there is an element of risk in the
activities my child may participate in while staying at MO-OK Deaf Youth Camp. I assume full responsibility for my
child, for any accident or injury that may occur while staying at MO-OK Deaf Youth Camp. I hereby release,
indemnify and hold harmless MO-OK Deaf Youth Camp, its agents and volunteers, from and against any and all
claims, liabilities, suits, actions, attorney’s fees, and including without limitation any act, omission, or negligence of
MO-OK Deaf Youth Camp, it’s agents, volunteers, which may arise from or in any way be connected with my child’
s stay or participation in activities at MO-OK Deaf Youth camp.
BOTH PARENTS/GUARDIANS SIGNATURE IS REQUIRED.
SIGNED: _____________________________ RELATIONSHIP: _______________ DATE: __________
SIGNED: _____________________________ RELATIONSHIP: _______________ DATE: __________
Please list as much as possible about your insurance and the deductible. Send a copy of your
insurance card, registration and completed Camper Health form and check/money order to:
Marsha Averill; 9443 High Hill; St. Louis, MO 63126
Checks should be made out to: Friendship Baptist Chapel of the Deaf/Deaf Youth Camp
DEADLINE for receiving application and fee is May 20, 2009
8/2008
Date Rec’d ___________
Copies Made ______________
Camper Health Form
Camper’s Name: _________________________________ Birth Date: _________________
Home Address: __________________________________________ Phone: ____________
Street or PO Box City State
Information on this form is to assist us in identifying appropriate care. This is to be completed by
parents/guardians of minors.
1. Communicable diseases, surgeries and/or serious illnesses: _________________________
2. Chronic or recurring illness or medical condition: __________________________________
3. Special dietary requirements and/or restrictions: ___________________________________
INSURANCE POLICY
Name of Policy Holder: _________________________________________________________
Phone Number: ______________________ Policy/Group #____________________________
Type of Coverage: ______________________________________________________________
Please include a copy of your insurance card
IMMUNICATION RECORD
VACCINE MONTH AND YEAR
IMMUNICATION WAS GIVEN
Diphtheria-Tetanus-Pertussis _____________________________________________
(DPT or Baby shots)
Tetanus – Diphtheria (TD) _____________________________________________
Tetanus _____________________________________________
Polio _____________________________________________
Measles (Hard, Red) _____________________________________________
Rubella (German Measles _____________________________________________
Mumps _____________________________________________
Other: _____________________________________________
ALLERGIES: (Please check all that applies to your child)
_____ Bee Sting _____ Poison Ivy _____ Pencillin _____ Poison Oak
_____ Sumac _____ Dust _____ Other (please list and explain) ____________
__________________________________________________________________________
PLEASE CHECK ALL THAT APPLIES TO YOUR CAMPER
_____ Asthma _____ Diabetic _____Takes cold easily _____ Sunburns easily
Name of Medication Dose in mg Amount/#to be given Time to be given Total #of Pills Nurse Initials
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
I give the nurse of MO-OK Deaf Youth Camp permission to administer the above medications as directed to my
camper.
_______________________________ ______________________________________ __________
NAME OF CAMPER SIGNATURE of Parent/Guardian Date
I give MO-OK Deaf Youth Camp’s nurse permission to administer the following over the counter medications as
needed to my camper according to the manufacturer’s directions. Please check all you wish to be given as
needed.
___ Tylenol ___ Ibuprofen ___ Chloraseptic spray ___ Halls Cough Drop
___ Caladryl Lotion ___ Antibiotic Ointment ___Sunburn spray/Lotion with Lidocain
________________________________________________________ ___________
Signature of parent/guardian Date
In the event I cannot be reached in an emergency, I hereby give permission for the physician selected by the
Camp Director or Camp Administrator, to hospitalize, secure proper treatment for, and to order injection,
anesthesia or surgery for my child ,__________________________, and will accept the expense of emergency
medical or surgical treatment.
_________________________________________ _______________________ _______________
Signature Relationship Date
8/2008
Return to Camper Information
Date Rec’d _____________
Date Pd. _______________
Check #:_______________
Scholarship: Yes or No
Date Pd. _______________
Check #:_______________
Scholarship: Yes or No
| June 7 - 12 2009 Deadline May 20 |