2009 WYR REGISTRATION
FEBRUARY 20 - 22, 2009 - AGES 12-17
APPLICATION AND REQUIRED MEDICAL FORM
Camper Full Name:
Male
Female:
Birthdate:
Address:
City:
State:
Zip:
Telephone:
E-mail (confirmation page
will be sent here):
Church:
Pastor:
Youth Sponsor:
MEDICAL INFORMATION
Parent/Guardian Name:
Emergency Contact:
Relationship:
Address:
City:
State:
Zip:
Emergency Contact Phone:
Medical Insurance Carrier:
Group No.:
Insurance Policy No.:
Allergies(drugs/other):
List any Medications camper
is currently taking:
