Ponca Church Camp 2018
First Baptist Church of Alma, Arkansas Medical Release Form/Permission to Treat
Child’s Name,
*
Child's Date of Birth and Grade Child is going into next fall
Parent/Guardian Name
Parent/Guardian Phone Number
*
Home Address
*
Emergency Contact
*
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?
*
No
Yes
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)
No
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
*
Total
$
Online Giving
Powered by Easy Tithe