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Youth Registration Form
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Name
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First
Last
Gender
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Age
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7
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Date of Birth
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Student Leadership Conference
Have you attended Tri-State before?
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Address
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Pastor's Name
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Church Address
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Your choice of one roommate
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Medical Information
Medications taken regularly
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(All medications sent to camp should be in their original labeled
containers
with proper dosing instructions attached.)
Allergies
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Which Shots is your camper up to date on? Check all that apply:
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Polio
Measels
Mumps
Rubella
Diptheria
Tetanus
Whooping Cough
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Last Tetanus Shot
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Physician's Name
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Physician's Phone Number
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Emergency Contact Name
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Emergency Contact Phone Number
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Insurance Provider
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Policy Number
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Insurance Phone Number
*
Parental Permission:
I have read the general information section in the brochure, and I agree to support TSBC is their dress and conduct regulations for my child while at camp. I understand that the camp reserves the right to send campers home that are non compliant with TSBC’s standards. I also agree to the use of photos, including my camper, in camp publicity. In the event of an emergency, I hereby give permission to the staff, directors and/or camp nurse at Tri-State to act as my agent in seeking medical treatment for my child. I also give my permission to the physicians selected by Tri-State to hospitalize and secure proper treatment and order anesthesia, surgery or any services deemed necessary for my child as named on this registration form. I understand every effort will be made to contact parents or guardians of campers in the event of an emergency. I understand that all off site medical expenses will be billed through the parents health insurance policy. I acknowledge all risks of injury and illness associated with my child attending camp including but not limited to those arising from Covid-19 exposure and illness and
hereby release the Tri-State Bible Camp/Conference Center of Montague, NJ, 07827, and it's staff and agents from all responsibility and liability for any injury or illness that my child may sustain while a camper at this facility.
I acknowledge there is a risk of exposure and illness associated with my child attending camp during the Covid-19 pandemic and agree to absolve Tri-State Bible Camp/Conference Center and it's staff and agents from any responsibility or liability for any exposure or illness that may occur from their attendance.
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No
I have read the above information and agree to abide by it. Please select "yes" if you agree and then type your name below.
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In lieu of signature, please type in your name.
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