Assemblies of God District Kids Camp Registration Form:

Name: 

Street Address: 

City, State & Zip: 

1.  Home Phone: 

2.  Work Phone: 

3.  Parent's Cell Phone: 

Best one to call in emergency:  1   2    3 

Age:                Grade: 

Parent's Names: 

Child's date of birth: 

Gender:  Male      Female 

Home Church: 

Senior Pastor: 

T-Shirt Size (adult sizes): Small    Medium    Large

Cabin Mate Requested: 

HEALTH & CONSENT FORM

Health Problems: 

Drug Allergies: 

Other Allergic Reactions: 

Polio Vaccination: Yes   No   Tetanus date: 

Activity Restrictions: 

Regular Medications: 

Insurance Company: 

Policy Number: 

Physician's Name: 

Physician's Phone: 

Click here to read and print out Parental Consent Form.