Camper Registration Form – P22 Youth Foundation

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Camper Registration Form

2024 Teen Spiritual Retreat Registration Form

Parent/Guardian Permission / Medical Information Form

With the completion and submission of this form, I give my child permission to attend and participate in the P22 Youth Foundation Teen Camping Spiritual Retreat at Mohican State Park, 3116 State Route 3, Loudonville, Ohio 44842 on Sunday, July 21st – Friday, July 26th, 2024

Camper Name

Age

Date of Birth

Camper Nickname

Gender

Male Female

Street Address (include City, State, ZipCode)

Parent/Guardian Information

Relationship to Camper

Phone Number(s)

Cell Phone

Work Phone

Emergency Contact Information

Relationship to Camper

Emergency Contact Phone Number

Health Insurance/Medical Information

Insurance Group Number

Medicaid/MMIS#

ID#

Policy#

Allergies

Prescription Medication

Medical Condition(s)

Tetanus Booster Date

Physical Limitations?

Yes No

Limitations Explanation

I agree

Use of Images: P22 Website and Promotional Materials:

I agree

General Release:

I agree

Medical Release:

I agree

Property Search Release:

I agree

Conduct Release:

I agree

Electronic Devices:

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Camper Registration Form