Ponca  Church Camp 2018
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?  * 
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.  * 
I want to pay this amount towards camp  * 
Your Email Address  * 
Total $
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