Name of Child

Gender Gender Male Female

Birthdate (eg. xx-xx-xxxx)

Age during session

School Attending

Parent or Legal Guardian Full Name

Home Phone

Work Phone

Street Address

City

State

Zip

1st Choice 1st Choice *Adventure Camp 1 | June 19-23 | 8-12 year oldsAdventure Camp 2 | June 26-30 | 9-13 year oldsJr Adventure Camp | July 5-7 | 7-8 year oldsTeen Camp | July 10-14 | 13-15 year oldsAdventure Camp 3 | July 17-21 | 8-12 year oldsAdventure Camp 4 | July 24-28 | 8-12 year olds

2nd Choice 2nd Choice *Adventure Camp 1 | June 19-23 | 8-12 year oldsAdventure Camp 2 | June 26-30 | 9-13 year oldsJr Adventure Camp | July 5-7 | 7-8 year oldsTeen Camp | July 10-14 | 13-15 year oldsAdventure Camp 3 | July 17-21 | 8-12 year oldsAdventure Camp 4 | July 24-28 | 8-12 year oldsAdventure Camp 5 | July 25-29 | 10-13 year olds

Check all boxes that apply: Check all boxes that apply: Diagnosed ADD or ADHD Nightmares Asthma Autism Sleepwalking Depression Frequent Nose Bleeds Diabetes Epilepsy Heart Disease Frequent Ear Infections Wets Bed

Wets Bed How Often? PLEASE SEND PULL UPS

Should any activities be restricted? Explain:

Are all immunizations current? Are all immunizations current? Yes No

Describe any hospitalizations or surgery (date, reason, problems):

Describe or list any chronic or serious past illnesses (include dates, medications, etc.):

List any known allergies to medications, foods, insects, pollens, inhalants or other: Please note any severe allergic reactions:

Preferred Hospital:

Insurance Name:

Insurance number:

Doctor's Name:

Doctor's Phone Number:

1st Contact Name:

Phone:

Address:

City:

State:

Zip:

2nd Contact Name:

Phone:

Address:

City:

State:

Zip:

List person(s) authorized to pick up your child. (YOUR CHILD WILL ONLY BE RELEASED TO THOSE ON THE LIST.)

Check-In Options Check-In Options South Side Mission - 9 AM Monday for Adventure Camps and Teen Camp, 9 AM Wednesday for Jr Adventure Camp. Camp Kearney - 11 AM Monday for Adventure Camps and Teen Camp, 11 AM Wednesday for Jr Adventure Camp.

Pick-Up Options Pick-Up Options South Side Mission - 3 PM Friday for Adventure Camp, Teen Camp and Jr Adventure Camp. Camp Kearney - 2 PM Friday for Adventure Camps, Teen Camp and Jr Adventure Camp.

Release Release The health history is correct so far as I know, and the child herein described has permission to engage in all prescribed camp activities, except as noted. I certify the emergency information is correct and that I or my 1st or 2nd contact listed will be available if the camper must be picked up from camp early. I will not hold the camp or its employees responsible or financially liable for any injuries or accidents that occur from participation in the camp program. I am willing to accept responsibility and liability for the inappropriate behavior of my child. I will not hold the camp or its staff responsible or financially liable for accidents caused by either my child or another child who is negligent. I understand that my child will receive non-denominational Christian religious instruction at camp. I give my permission for the First Aid Supervisor to give my child over the counter medication if the situation requires it. South Side Mission may use pictures of this child for camp advertising. I agree to use my insurance or medical card in case of medical treatment arising out of camp participation. In the event I cannot be reached in an emergency, I give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child, as named above. Check here if DCFS exempt and list DCFS emergency “permission to treat” number:

Name of person to authorize

Number of person to authorize

Agreed to by:

Date:

Relationship to Child: (parent or legal guardians ONLY)

Has the state of IL put this child on a plan requiring separate bathing and sleeping quarters? (SASS plan) Has the state of IL put this child on a plan requiring separate bathing and sleeping quarters? (SASS plan) Yes No

Ibuprofen Ibuprofen Yes No

Tylenol Tylenol Yes No

Topical Cream Topical Cream Yes No

Sudafed Sudafed Yes No

Anti-Diarrhea Anti-Diarrhea Yes No

Cough Drops Cough Drops Yes No

Benadryl Benadryl Yes No

Cough Suppressants Cough Suppressants Yes No

Antacids Antacids Yes No

Name

Date