Grade in 2011-2012:
Will your child be
on medication this summer?
If Yes, list
Will they need to
take their medication while at camp?
Does your child
have any allergies that we should be aware of?
Would you like to
receive a form to list your child's allergies and/or medications in
this box, I agree to the following: (REQUIRED)
In the event I cannot be reached in an emergency, I hereby
give my permission to the physician selected by Union Gospel
Mission to hospitalize, to secure proper treatment for and/or
order an injection, anesthesia, or surgery for my child as deemed
By this Agreement, I authorize Gospel Hill Camp
staff/agent to administer First Aid (including over-the-counter
medicines) as required for illness and injury. The signature of
the parent or guardian below is intended to serve as a medical
As parent or guardian of the above-named camper, I hereby
agree to allow him/her to participate in all Gospel Hill Camp
activities. I realize that unanticipated and unexpected dangers
may arise during and associated with the camp activities. I
voluntarily agree to accept any and all risks of injury arising
from the camp activities.
Union Gospel Mission may use comments, photos, and video of
the camper named above in its promotional materials.
I have carefully read this agreement and fully understand its
contents. I am aware that this is a release of liability and
medical release. I am agreeing to it of my own free will.
would your child like to attend? (Check all that you would
• June 11 - July 6, 2012
• July 23 - August 17, 2012
April 27 - $13 per session
May 11 - $15 per session
After May 11 - $20 per
• June 13 - 15, 2012
• June 18 - 22, 2012
Boys & Girls Sports Camp
• July 9 - 13, 2012
May 11 - $8 per camp
After May 11 - $10 per
• June 25 - 29, 2012
• July 16 - 20, 2012
• July 30 - August 3, 2012
• August 5 -10, 2012
1 camp - $15
2 camps - $20 (save
3 camps - $24