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ABOUT
STAFF
WHAT WE BELIEVE
OPPORTUNITIES
EVENTS
VISIT
SERMONS
CONTACT
ABOUT
STAFF
WHAT WE BELIEVE
OPPORTUNITIES
EVENTS
VISIT
SERMONS
CONTACT
PD Day Camp
Child's Name
Grade
VPK
Kindergarten
First
Second
Third
Fourth
Fifth
Sixth
Seventh
Eighth
Ninth
Tenth
Eleventh
Twelfth
Birthday
Age
Parent's Name
Home Address
City
State
Zip
Email Address
Parent's Phone
Alternate Phone
People Who May Pick Up The Child
Emergency Contact Name
Emergency Contact Phone
Emergency Contact Work Phone
Relationship to Camper
Child's Physician
Physician Phone
Insurance Company
Policy Number
Insurance Company Address
Allergies/Physical Restrictions
Dietary Restrictions
Parent/Guardian Name
Date - Medical Consent
OTC Medical Permission
I give permission for camp staff to administer over-the-counter medication as needed
I do not want any over-the-counter medication administered to my child
Camper will NOT take any daily medications while attending camp
Camper will take daily medication(s) listed below while at camp
List of Daily Medications Taken While At Camp
General Health History
Allergies
Anemia
Asthma
Back Problems
Bleeding Disorder
Broken Bones
Cancer
Chest Pain
Chronic Pain
Contacts/glasses
Convulsions/Seizures
Diabetes
Fainting
Frequent Ear Infections
Frequent Headaches
Hearing Problems
Heart Disease
High Blood Pressure
Hospitalization in past 12 months
Kidney Problems
Liver Problems
Low Blood Pressure
Sleep Problems
Skin Conditions
Sports Injuries
Stomach Problems
Surgery in the last 12 months
Thyroid Problems
Vision Problems
Explain any YES answers
Mental/Social/Emotional Health
Has been treated for ADD or ADHD
Takes ADD/ADHD medication during school year only
Takes ADHD medication during summer
Has been treated for emotional or behavioral difficulties or an eating disorder
Has seen a professional for mental/emotional health concerns in the past 12 months
Other Mental/Emotional Health Concerns
Explain YES answers for Mental/Social/Emotional Health
The Village Church leaders have permission to photograph/film the minor(s) designated above in any manner or form for any lawful purpose associated with this camp
Yes
No
Camper Last Name
Camper First Name
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