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MID-SOUTH YOUTH CAMP 2025


First Camper's Name

First Name*

Middle Name

Last Name*
First Camper's 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*
Second Camper's 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*
Third Camper's 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*
Fourth Camper's 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*
Fifth Camper's 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*
Sixth Camper's 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*
Seventh Camper's 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*
Eighth Camper's 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*
Ninth Camper's 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*
Tenth Camper's 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*
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*
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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