Camp Adventure 2021

Camper Name (required)

Age (required)

Date of birth (required)

Gender (required)

Address (required)

Primary Phone (required)

School (required)

Grade (required)

PRIMARY CONTACT INFORMATION:

Primary Contact (required)

Relationship to Member (required)

Cell (required)

Employer (required)

Work Phone (required)

Email (required)

MEDICAL INFORMATION:

Daily Medication Needed (required)

In the event I cannot be contacted, I give the Birdsboro Community Memorial Center permission to obtain emergency medical care for my child at the nearest hospital

Permission Initial (required)

Insurance Carrier (required)

Does the member have any special needs/health issues (include allergies) (required)

Any Medications (required)

Any other medical information our staff should know about (required)

I hereby give permission and consent for my child to participate in any and all activities provided by Camp Adventure. I understand that all safety precautions will be taken and I will not hold the BCMC, it’s staff, volunteers, or officials legally liable for any damage suffered by my child including any personal injury, bodily injury, including dental, which arises out of my child’s participating in its activity, program, or field trip.

Initial Consent (required)

Please fill out anybody who is authorized to pick up our campers, and their relationship to the camper:
If on any given day, one of the listed below people are not able to pick up your child, you must call BCMC to inform who is picking them up. (Please provide BCMC with any documentation of custody / divorce issues that may arise with pick up)
Name and Relationship:
Example: John Smith - Father
(required)

Guardian Signature (required)

Application Date (required)

 
We WILL NOT sell or share your information with any other companies. We DO NOT Spam.