Pilot Lake Registration & Medical Release
Church: Camp Dates:
Name:
Address:
Email Address:
Parent/Guardian Name:
Alt Emergency Contact:
(not at camp)
Are your immunizations current?
Current Medications:
Medical Conditions, Allergies
and other Special Needs:
Date of Birth:
Phone:
Phone:
Phone:
Activity Restrictions:
Health Information
The Church Who Is Organizing Your Camp
Participant Information
PLEASE NOTE:
1. State law requires all medications, OTCs, and supplements be turned over to the camp nurse.
2. Prescriptions must be in the original container, labeled with the prescription including the
participant's name and dosage instructions.
Last Tetanus shot:
3. Supplements and Over The Counter (OTC) Medications must be in the original sealed
container with the participant's name on it. OTC medications such as Tylenol, Motrin, Sudafed,
Benadryl, Acetaminophen, Ibuprofen, Pseudoephedrine, and Diphenhydramine may be
available
from the camp nurse as needed.
4. Questions regarding the above may be directed via email to the camp director.
The following OTC medications are not to be given:
I understand that Pilot Lake (Regular Baptist Camp, Inc.) does not provide medical coverage, nor
reimburses for medical expenses that may arise from illness or injury while at Pilot Lake, and that
my insurance may be charged for medical services performed. I give my permission for myself or
my child to receive any medical or dental attention deemed necessary because of such illness or
injury. Furthermore, I give permission for any quotes or pictures of myself or my child taken during
camp to be used by Pilot Lake for promotional purposes. I hereby release Pilot Lake (Regular
Baptist Camp) and its staff of any liability. I understand every effort will be made to contact those
listed above.
Signature:
Parent/Guardian Name:
Parent/Guardian Signature: Date: