Intermediate Camp | Bethany Farm Camp

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Registration-Summer Camp

First Name

Last Name

Male/Female

Street Address

City

Parent/Guardian Name

Parent/Guardian Phone

Parent/ Guardian's Email

Emergency Contact Name

Emergency Contact Phone Number

Date of Birth

Grade Entering This Fall

Allergic Reaction/Drug Allergies

Most Recent Tetinus

Regular Medication Instructions

Activity/Dietary Restrictions

Permission To Administer Over-The-Counter Drugs

Drug Brands

Dosage

Family Doctor Name

Insurance Provider Company

Policy Number

Insured"s Name

Any Other Medical Information

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