Student Name:*

Male
Female

Date of Birth: (Month, Day, Year):*

Grade Entering (Fall of 2011)

T-Shirt Size (adult sizes only)
S
M
L
XL

Family/Emergency Contact Information

Emergency Contact (Parent or Guardian):*

Home Phone:*

Cell Phone:

Street Address:*

City:*

State:*

Zip Code:*

Email Address:*

Church Contact Information

Name of Church Attended (or facilitating):*

Church Phone:*

Church Fax (if available)

Church Address:*

City:*

State:*

Zip:*

Youth Leader Name (or designated church contact) :*

Youth Leader Contact Home Phone:*

Youth Leader Contact Cell Phone:

Youth Leader Email Address:*

Medical Information

Name of Insurance Provider (Company Name):*

Name of Insured (Primary Policy Holder Name):*

Policy Number:*

Group Number:*

Claims Phone Number:*

Known Allergies or Required Dietary Restrictions of Camper

Special Health Considerations of Camper (Asthma, Diabetes, Epilepsy, Other)

Medications: Indicate any medications camper will be taking at RYC. Including dosage and timing information.

List any other medical or physical restrictions for camper while at RYC

I authorize all medical and surgical treatment, X-ray, laboratory, anesthesia, and other medical and/or hospital procedures as may be performed or prescribed by the attending physician and/or paramedics for my child and waive my right to informed consent of treatment. This waiver applies only in the event that the listed contact cannot be reached in the case of an emergency. I release RYC, LSOPC and individuals from liability in case of accident during, or activities related to, RYC.

Parent's/Guardians Signature:*

Date

* Indicates required field