LCU Summer Camp Application

Parent Information

Full Name:

Address:

Street Address

Apartment/Unit #

city

State

Zip Code

Phone:

Email:

Spouse's Name:

Camper Information

Full Name:

Camper Cell Phone:

T Shirt Size:

Email:

Birth Date:

Gender:

Graduation Year:

Emergency Contact Information

Home Church:

Youth Minister:

Mother Cell:

Father Cell:

Primary Emergency Contact Number:

Insurance/Health Information

Doctor's Name:

Doctor's Phone Number:

Health Insurance Plan:

Policy Holder Name:

Policy Number:

Group Number:

Allergies:

Medication:

Injuries or any other health history we should be aware of?

Do you give permission for the camp nurse to give over the counter medication to your camper if needed?

Yes No

Camp Attending:

Encounter Camp Champion