MY CHILD
WANTS TO ATTEND FAMILY CAMP 2002!
JULY 1st - 7th
Child's Name:____________________________
Date of Birth:_____________
Parent's
Name:______________________________ Sex:______
Address:__________________________________________________________
City:_______________________________________
State:_____ Zip:________
Emergency Phone Number:
_______________________
MEDICAL
RELEASE/INSURANCE INFORMATION
I hereby give consent that any necessary
medical treatment may be given to
_____________________ by medical personnel in case of
accident or illness. By my signature below, I
understand that expenses for medical care will be my
responsibility.
Signature
______________________________________ (if
18 or over please sign; if a minor, parent/guardian
must sign)
Special Medical
Conditions:____________________________________________
Insurance
Carrier:____________________________________________________
Policy #
___________________________________________________________
Please list any allergies/medications on
an additional sheet of paper.
Please photocopy form for additional
children
You may Print this form then complete and
mail it to:
LHBC
PO Box 21516
Hot Springs, AR 71903
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to May/June 2002 Voices