Parent/Guardian Application and Consent Form for Pleasant Valley Christian Camp 2001

Puget Sound Christian Service Camp

E-mail:
PLEASANT VALLEY CHRISTIAN CAMP

P.O. Box 175 Mineral, WA 98355
1-800-789-9841

Parent/Guardian Application and Consent Form

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Parent/Guardian of Camper: PLEASE PRINT! You must complete and sign this application. Please read the release form carefully.

This application is made with my approval. I shall indemnify and hold harmless Puget Sound Christian Service Camp (also known as Pleasant Valley Christian Camp) and any and all of its personnel of any and all claims of any nature and manner over and above the insurance included in the registration fee, but not limited to the same. I grant my permission for emergency medical treatment deemed necessary by the camp management and attending physician.

Signature of Parent/Guardian______________________________ Date_______

Insurance Company:_______________________________________________
(Camp is secondary insurer)

Work Phone: (____)__________________

Alternate/Emergency Phone: (____)_______________

Complete the following information. Use additional sheet if needed:
Is the camper allergic to any food or drugs? Yes

If yes, explain: ________________________________________________________

________________________________________________________

When was the last tetanus shot administered?_____________________________

List any medications the camper is currently taking:___________________________________________________

________________________________________________________

NOTE: Prescription medications must be sent to camp in their original container.

Does the camp nurse have your permission to administer the following if needed? Ibuprofen (or Aspirin Products) Over the Counter Allergy Med's Tylenol

Parent/Guardian of Camper: PLEASE PRINT! This form must be received in order for application to be considered complete.

Mail completed form and fees to:
Pleasant Valley Registrar
c/o Shoreline Christian Church
14800 First Ave. N.E., Shoreline, WA 98155
1-800-789-9841 • Fax: 206-364-3288
E-mail: pvccpam@juno.com
Or register online: www.pleasantvalleycamp.org