Camper Name *

First Name

Last Name

Parent/Guardian's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Preferred Phone Number *

(###)

###

####

Additional Phone Number

(###)

###

####

Camper Date of Birth *

MM

DD

YYYY

Camper Gender *

Female

Male

Grade Completed this Year *

2

3

4

5

6

7

Are You an Angel Tree Camper *

No

Yes

Emergency contact other than Parent/guardian *

First Name

Last Name

Emergency Contact's Preferred Phone Number *

(###)

###

####

Additional Phone Number

(###)

###

####

Do you have medical insurance *

No

Yes

Name of Family Physician

First Name

Last Name

Family Physicians Phone Number

(###)

###

####

I authorize Camp Eagle Counselors to administer the prescription medications to the camper while he/she is a camper at Camp Eagle in the absence of the Camp Eagle Nurse. I understand and am aware the prescription medications are administered by the Camp Nurse at Camp Eagle. *

No

Yes

I authorize Camp Eagle Counselors to administer over-the-counter medications to the camper while he/she is a camper at Camp Eagle in the absence of the Camp Eagle Nurse. I understand and am aware the over-the-counter medications are administered by the Camp Nurse at Camp Eagle. *

No

Yes

Acetaminophen (Tylenol Tablet or Liquid) *

No

Yes

Antibiotic Cream (Neosporin Ointment) *

No

Yes

Antihistamines (Benadryl Tablets/Liquid) *

No

Yes

Calamine Lotion *

No

Yes

Hydrocortisone Cream *

No

Yes

Ibuprofen (Advil Tablets/Liquid) *

No

Yes

Insect Repellent *

No

Yes

Pepto-Bismol Tablets/Liquid (Non-Aspirin tablets for campers 12 years and under) *

No

Yes

Sunscreen *

No

Yes

Does your camper use an EpiPen *

No

Yes

Medical Authorization & Assumption of Risk & Indemnity Agreement: By registering your child for any event you are agreeing to the following statements: In the case of a medical emergency, I hereby give my permission to have the staff member in charge hospitalize my child and/or secure a licensed physician, surgeon, or anesthetist to provide the necessary care for my child as named on this registration form. I certify my child is in good physical health and is able to participate in the entire camping program, except for the activities listed as restricted. I understand and agree that I will be responsible for any and all expenses associated with providing medical care for my child. I am aware that during certain events and activities on Camp Eagle property, there may be inherent risks associated with this as well as any other outdoor activity. These events include, but are not limited to, High and Low Ropes Courses, Swimming, Hiking, Challenge Courses, Team Building Exercises, games, paintball, The Blob, Hay Rides, archery, BB guns, tomahawk throwing, sling shots, and all other camp related activities. Since Camper safety is of utmost importance to the Camp Eagle Staff, I agree that once made aware of the rules, regulations, and standards as set forth by Camp Eagle instructors, I will abide by them or accept dismissal without the benefit of refund for refusing to follow such rules. In consideration of and as part payment for the right to participate in these events and activities, I have and do hereby assume all risks and will hold Camp Eagle and its sponsoring organization, Shenandoah Baptist Church, (along with all employees or agents of Camp Eagle and Shenandoah Baptist Church), harmless from any and all liability, actions, causes of action, debts, claims and demands of every kind and nature whatsoever which I now have or which may arise from or in connection with my and/or my child’s participation in outdoor program activities arranged for me and/or others by Camp Eagle. The terms hereof shall serve as a RELEASE AND ASSUMPTION OF RISKS and INDEMNITY for my heirs, executors, and administrators and for all members of my family. If the participant is a minor, the undersigned parent or guardian gives permission for said minor to participate in events and activities sponsored by Camp Eagle and accept all risks as stated above. I hereby give permission for my child or children to be photographed or videotaped while participating in the events at Camp Eagle. I give Camp Eagle and their agents permission to use or distribute such photographs or video for any reasonable purpose including advertising or promotion. I understand this consent complies with Section 8.01-40 of the Code of Virginia or its equivalent. I have carefully read all the information from the webpage, www.campeagleva.org/faqs, and agree to cooperate and comply in all these areas. I understand that violations in any of these areas may result in the campers dismissal from Camp Eagle. *

I have read the Medical Authorization & Assumption of Risk statement.

Parental Consent *

I Agree

First Name

Last Name

Date Form Signed *

MM

DD

YYYY