Super Summer Youth Camp
Super Summer Youth Camp
This camp is for outgoing 9-12th graders we will be attending Super Summer AR at Ouachita Baptist University's campus June 25th-29th
Be sure to sign up before April 30th to get room preferences and the last day to sign up is May 19th
For more information contact our Student Pastor J.D. Finley at 479-462-4304 or
Childs Name (First and Last)  * 
Date of Birth  * 
Childs Age  * 
Student is a  * 
Student Cell Phone Number  * 
T-Shirt Size  * 
Home Address  * 
Parent or Guardian Name (First and Last)  * 
Parent or Guardian Contact Phone Number  * 
Relationship to Child  * 
Secondary Emergency Contact Name (First and Last)  * 
Secondary Emergency Contact Phone Number  * 
Physicians Name:
Physicians Phone Number:
Insurance Information:
Insurance Company Name  * 
Group #
Policy #
Relationship to Child
Insurance Company Phone Number
Information packet will be handed out closer to camp time with releases and consent forms to be signed.
Personal Medical Information:
Does the student have food allergies?  * 
Does your child have an Epi-Pen?  * 
Please list physical limitations (Asthma, diabetes, allergies, etc.) and/or special instructions (allergic to certain meds, rare blood type, wears contacts, etc.)
Is your child on any medications? If so, please list medication name, dosage and purpose: (must have pharmacy label and Dr's name on it)  * 
Please list all operations/serious injuries and dates within the past 5 years.
Date of last tetanus shot  * 
Is the student's immunizations and vaccinations current? If not, please explain.  * 
I would like to pay $ 
Your Email Address  * 
I want to pay (select from drop down menu) Total amount for this camp is $200.00
Total $
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