Registration Winter Retreat Camper's Name(required) Gender MaleFemale Birth Date(required) grade(required) Address(required) City(required) State(required) Zip(required) Parent/Guardian(required) Home Phone Cell Phone Email address Home Church Your Pastor Camper's Physician Physician's phone Insurance Company Policy Holder Policy number Date of last tetanus shot Preexisting Medical Conditions List all allergies - medications, foods, insects, etc. List all regularly used medications List all restricted activities I gave my child permission to take (required) TylenolIbuprofenNeither Pick your week (required) January 25-27, 2018February 1-3, 2018 In case of a medical emergency, I understand that every effort will be made to contact me, the parent or guardian of the camper. In the event that I cannot be reached, I hereby give permission to the physician selected by the camp director or camp nurse to hospitalize and secure proper treatment for an injection, anesthesia, surgery, or whatever is needed for the child named above. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. In addition to the medical release, I also grant SHCM permission to take photographs and/or videos of the above named camper. I authorize SHCM to use or publish the same in print or electronically. Note: All claims must be submitted to your personal insurance company. Signature of parent or guardian. By typing your name, you agree that you are the parent or guardian of the above named camper. Click the "send" button to submit your registration. After you receive the message "Your message was sent successfully. Thanks." proceed to the PayPal options. Do not click the PayPal links until after you have clicked the “send” button. To pay only the $25.00 registration fee, click the following link. To pay only the total $90.00 fee, click the following link.