Mississippi Valley Christian Service Camp
Registration Card (Front)

Campers Name_____________________________________________Age_________Sex M F

Complete Mailing Address______________________________________________________

Home Phone______________Parents Work Phone______________ Cell_________________

Email Address _________________________________________(solely for use of MVCSC)

 Who will be picking your camper up at the close of camp? ____________________

Name of Church_________________________Are you a member? _____________

What grade will your camper enter this fall?_________________________________

Camper's Birthday _____________________________________________________

What week will your camper be attending? __________________________________

Health Record:
What restrictions, if any, should be observed in ACTIVE camp life?______________________________________________________________________
Indicate any medication to which applicant reacts adversely and which therefore should not be administered:____________________________________________________________
Name of family physician_____________________Address___________________________________
Physician's phone number________________________________________________
Indicate any special instructions the camp nurse should know:__________________________________________________________________
The campers will be supervised and if serious illness or injury develops, medical and/or hospital care will be provided. I further understand that in case of serious injury or illness, I will be notified. If it is impossible to contact me, I give permission for emergency treatment of surgery as recommended by the attending physician. I have read and understand the above information.
_______________________________________________________________________
Parent or Guardian Signature Date