Page 60 | Restoration Purpose Church

Camper Name: (Required)

First and Last

Address: (Required)

Email: (Required)

Primary Phone:

Date of birth: (Required)

Age: (Required)

T-Shirt Size: (Required)

Emergency Contact 1: (Required)

First and Last

Phone: (Required)

Emergency Contact 1

Address: (Required)

Emergency Contact 1

Emergency Contact 2: (Required)

Phone: (Required)

Emergency Contact 2

Address: (Required)

Emergency Contact 2

Does Camper have any allergies? (Required)

If Camper has allergy, please list them here:

Does Camper have activity restrictions? (Required)

If Camper has activity restrictions, please list them here:

Does Camper have a chronic physical condition? (Required)

If Camper has chronic physical conditions, please list them here:

Does Camper require any special dietary needs? (Such as Gluten-free, diabetic needs, etc.) (Required)

If Camper does require special dietary needs, please list them here:

Does Camper have any required medications? (Required)

If Camper has required medications, please list the name, dosage and how many times per day here:

Has Camper been tested or treated for any serious physical or psychological illness within the past 3 years? (Required)

If Camper has been tested or treated for a serious physical or psychological illness within the past 3 years, please list them here:

Family Physician Name: (Required)

Family Physician Phone Number: (Required)

Insurance Company: (Required)

Insurance Group Number: (Required)

Insurance Individual Number: (Required)

Please email a copy of Campers insurance card FRONT AND BACK to Restorationpurposechurch@gmail.com

Restoration Purpose Church