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MID-SOUTH YOUTH CAMP 2025


First Camper's Name
First Name*
Middle Name
Last Name*
Select Gender
First Camper's Date of Birth*
Date of Birth
First Camper's Information
INSURANCE ID *
CURRENT AGE *
LAST GRADE ATTENDED *
Can Camp Staff give over-the-counter medicine to your camper? *
Special Dietary Needs, Health Problems, Allergies
Medication Instructions (If Any)
Other Comments Staff Should Know Regarding Camper
First Camper's Signature*
Second Camper's Name
First Name*
Middle Name
Last Name*
Select Gender
Camper's Date of Birth*
Date of Birth
Second Camper's Information
INSURANCE ID *
CURRENT AGE *
LAST GRADE ATTENDED *
Can Camp Staff give over-the-counter medicine to your camper? *
Special Dietary Needs, Health Problems, Allergies
Medication Instructions (If Any)
Other Comments Staff Should Know Regarding Camper
Third Camper's Name
First Name*
Middle Name
Last Name*
Select Gender
Camper's Date of Birth*
Date of Birth
Third Camper's Information
INSURANCE ID *
CURRENT AGE *
LAST GRADE ATTENDED *
Can Camp Staff give over-the-counter medicine to your camper? *
Special Dietary Needs, Health Problems, Allergies
Medication Instructions (If Any)
Other Comments Staff Should Know Regarding Camper
Fourth Camper's Name
First Name*
Middle Name
Last Name*
Select Gender
Camper's Date of Birth*
Date of Birth
Fourth Camper's Information
INSURANCE ID *
CURRENT AGE *
LAST GRADE ATTENDED *
Can Camp Staff give over-the-counter medicine to your camper? *
Special Dietary Needs, Health Problems, Allergies
Medication Instructions (If Any)
Other Comments Staff Should Know Regarding Camper
Fifth Camper's Name
First Name*
Middle Name
Last Name*
Select Gender
Camper's Date of Birth*
Date of Birth
Fifth Camper's Information
INSURANCE ID *
CURRENT AGE *
LAST GRADE ATTENDED *
Can Camp Staff give over-the-counter medicine to your camper? *
Special Dietary Needs, Health Problems, Allergies
Medication Instructions (If Any)
Other Comments Staff Should Know Regarding Camper
Sixth Camper's Name
First Name*
Middle Name
Last Name*
Select Gender
Camper's Date of Birth*
Date of Birth
Sixth Camper's Information
INSURANCE ID *
CURRENT AGE *
LAST GRADE ATTENDED *
Can Camp Staff give over-the-counter medicine to your camper? *
Special Dietary Needs, Health Problems, Allergies
Medication Instructions (If Any)
Other Comments Staff Should Know Regarding Camper
Seventh Camper's Name
First Name*
Middle Name
Last Name*
Select Gender
Camper's Date of Birth*
Date of Birth
Seventh Camper's Information
INSURANCE ID *
CURRENT AGE *
LAST GRADE ATTENDED *
Can Camp Staff give over-the-counter medicine to your camper? *
Special Dietary Needs, Health Problems, Allergies
Medication Instructions (If Any)
Other Comments Staff Should Know Regarding Camper
Eighth Camper's Name
First Name*
Middle Name
Last Name*
Select Gender
Camper's Date of Birth*
Date of Birth
Eighth Camper's Information
INSURANCE ID *
CURRENT AGE *
LAST GRADE ATTENDED *
Can Camp Staff give over-the-counter medicine to your camper? *
Special Dietary Needs, Health Problems, Allergies
Medication Instructions (If Any)
Other Comments Staff Should Know Regarding Camper
Ninth Camper's Name
First Name*
Middle Name
Last Name*
Select Gender
Camper's Date of Birth*
Date of Birth
Ninth Camper's Information
INSURANCE ID *
CURRENT AGE *
LAST GRADE ATTENDED *
Can Camp Staff give over-the-counter medicine to your camper? *
Special Dietary Needs, Health Problems, Allergies
Medication Instructions (If Any)
Other Comments Staff Should Know Regarding Camper
Tenth Camper's Name
First Name*
Middle Name
Last Name*
Select Gender
Camper's Date of Birth*
Date of Birth
Tenth Camper's Information
INSURANCE ID *
CURRENT AGE *
LAST GRADE ATTENDED *
Can Camp Staff give over-the-counter medicine to your camper? *
Special Dietary Needs, Health Problems, Allergies
Medication Instructions (If Any)
Other Comments Staff Should Know Regarding Camper
Parent or Guardian's Email Address
Email*
Confirm Email*
Back-up Emergency Telephone Number
Provide secondary phone number in case of emergency *
Parent(s) or Court-Appointed Legal Guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name
First Name*
Middle Name
Last Name*
Relationship*
Phone*
Select Gender
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Date of Birth*
Date of Birth
Parent or Guardian's Information
INSURANCE ID *
CURRENT AGE *
LAST GRADE ATTENDED *
Can Camp Staff give over-the-counter medicine to your camper? *
Special Dietary Needs, Health Problems, Allergies
Medication Instructions (If Any)
Other Comments Staff Should Know Regarding Camper
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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