Name: Phone: Name: Birth Date
Accident and illness coverage is the responsibility of the parent/guardian or participant. An up-to-date copy of this form must be presented for EACH participant who attends. It is the responsibility of the registered participant and/or their parent/ legal guardian to provide Camp Cross with any changes in medical history or medication. In any emergency please notify the following person.
Name: Relationship to participant(s): Address: Phone:
Insurance Carrier: Policy #:
Group #:
Name:
Phone:
Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Gender: (M) or (F)
Date of last Tetanus Toxoid:
Immunizations are required for all YOUTH CAMPERS and must be up-to-date within 12 months prior to the camp session check-in date. Parents/guardians must furnish a “certificate of immunization status” by mail or at the time of check-in for their camper. An exemption may be claimed on the basis of medical, religious, or personal reasons with signatures from the legal parent/guardian and a licensed healthcare provider. RECORDS ARE NOT REQUIRED FOR FAMILY/ADULT SESSION CAMPERS. A COPY OF THE PARTICIPANT’S SCHOOL IMMUNIZATION RECORD IS AN ACCEPTABLE FORM OF AN IMMUNIZATION RECORD. For a blank form of an immunization record form to download and print, please go to the Camp Cross website, www.campcross.org. Copies of immunization records ARE REQUIRED FOR YOUTH SESSION CAMPERS, unless you have a waiver from a doctor. I understand that I must provide an immunization record to Camp Cross
Please fill out the Family Participants if you have chosen to attend a family camp. This form has up to 5 spaces including the participant on the first page. For larger families please contact the Camp Cross registrar at the Episcopal Diocese of Spokane 509-624-3191.
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
1
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
2
Name: Relationship to participant(s): Address: Phone:
Insurance Carrier: Policy #:
Group #:
Name:
Phone:
Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Gender: (M) or (F)
Date of last Tetanus Toxoid:
Immunizations are required for all YOUTH CAMPERS and must be up-to-date within 12 months prior to the camp session check-in date. Parents/guardians must furnish a “certificate of immunization status” by mail or at the time of check-in for their camper. An exemption may be claimed on the basis of medical, religious, or personal reasons with signatures from the legal parent/guardian and a licensed healthcare provider. RECORDS ARE NOT REQUIRED FOR FAMILY/ADULT SESSION CAMPERS. A COPY OF THE PARTICIPANT’S SCHOOL IMMUNIZATION RECORD IS AN ACCEPTABLE FORM OF AN IMMUNIZATION RECORD. For a blank form of an immunization record form to download and print, please go to the Camp Cross website, www.campcross.org. Copies of immunization records ARE REQUIRED FOR YOUTH SESSION CAMPERS, unless you have a waiver from a doctor. I understand that I must provide an immunization record to Camp Cross
Please fill out the Family Participants if you have chosen to attend a family camp. This form has up to 5 spaces including the participant on the first page. For larger families please contact the Camp Cross registrar at the Episcopal Diocese of Spokane 509-624-3191.
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
1
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Participant Name: Dietary requirements: Allergies: Medical or developmental conditions: Limitations: Immunizations: Prescription Medications/Dosage:
Birth Date:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
Gender: (M) or (F)
Date of Last Tetanus Toxoid:
2
