Refuge Jr High Summer Camp

Student Name

Grade Level for 2026-2027 School Year Grade Level for 2026-2027 School Year *6th Grade7th Grade8th Grade

Gender Gender *MaleFemale

Parent Name

Parent Phone Number

Parent Email

Emergency Contact (Other than first Parent)

Emergency Contact Phone Number

Emergency Contact Relationship

Insurance Provider and Policy Number

Are the campers immunizations up to date, including tetanus shot? Are the campers immunizations up to date, including tetanus shot? *YesNo

If camper requires medication during camp, please list medication name, dosage and frequency.

If the camper has an allergy or special dietary need please list all foods, medications, and substances below.

If the camper has any chronic health concerns please list them below and give normal treatment details (e.g. asthma, hearing difficulties, insect stings, fears/phobias, headaches, heart condition, seizure disorder, sleep walking, diabetes, bedwetting, fainting, etc...)

Signature MEDICAL ANDLIABILITY RELEASE: (You may sign your own release is you are 18 or older) By Signing this you acknowledge that you have read the terms and conditions and verify that the health history is correct. The undersigned does hereby give permission for my child, to attend and participate in activities sponsored by Grace Evangelical Free Church for the date of June 19th- June 22nd. I will not hold Grace Evangelical Free Church and its agents, the campground (Hartstone Bible Camp) and its agents liable for injury caused by common accident, illness, or the rendering of emergency care. If I cannot be reached in an emergency, I authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examinations, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned does also hereby give permission for my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Grace Evangelical Free Church. By also signing this document, the undersigned gives permission for my child’s likeness in the form of still picture and/or video and audio to be used in any church sponsored promotional material.