A.  I certify that (camper's name)____________________________________ is in good physical health and carries not illness that would endanger the health of other campers or staff.

B.  Camper's Age:_____  Birthday:__________ Date of last tetanus or booster:__________

C.  Emergency phone numbers:  Day:_______________ Night:______________ Cell:______________

D.  List any known allergies (plant, animal, bee, medicine, etc.:__________________________________________

E.  List any medications the camper will bring to camp:________________________________________________

F.  I acknowledge that accident Insurance only is provided by Southern Illinois Christian Service Camp, which will go into effect after our family insurance has been charged or if I have no insurance.  If my child becomes ill and is subsequently hospitalized, or family insurance or me personally will be responsible.

G.  I  here by release the management, staff, volunteer workers, or officers of Southern Illinois Christian Service Camp of any responsibility for accidents unless guilty of negligence.

H.  In case of emergency, I hereby give permission to the physician selected by the camp management to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child named above on this form.  I understand, however, that every effort will be made to contact me incase of any such emergency before any such treatment is administered.

I.  I give permission for camp photos or videos that include my child to be used for camp promotion.

Signature of Parent or Guardian_________________________________________ Date:___________________

(Office Use:  Cabin_____ Bunk_____Group_____)