Ponca Church Camp 2017
First Baptist Church of Alma, Arkansas Medical Release Form/Permission to Treat
Child's Date of Birth and Grade Child is going into next fall
Parent/Guardian Phone Number
Emergency Contact Phone Number
Relationship to Child
Does your child have any other allergies or conditions we need to know about? If so, please list here:
Is your child on any medications? If so, please list medication name and dosage: (prescription meds MUST have pharmacy label with Doctors name)
Please list your child’s insurance information. Company name, policy number, policy holder name:
Can your child swim?
Is there any activities that should be restricted due to health or safety issues?
What size t-shirt does your child wear?
I want to add a camp t-shirt.
Yes (Add $10.00)
I want to pay this amount towards camp
Deposit (Add $25.00)
1/2 of camp (Add $49.50)
Rest of camp after deposit (Add $74.00)
I want to pay office
Your Email Address
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