Register - Heritage Youth Camp 2025

What is your full name?

What is your date of birth?:

What is your home address?:

Parent's Phone Number:

Parent's Email:

Shirt Preference Would you like a short sleeve or long sleeve shirt?

Shirt Size

Okay great! What size?

Church Information Do you attend a church?
Yes No

Emergency Contact Emergency Contact Name:

Emergency Contact Number:

Medical History Dietary Restrictions:
Gluten Intolerant
Lactose Intolerant
Vegetarian
None
Other:

Allergies:
Food
Medication
Environmental (stings, hay fever, etc.)
No Known Allergies
Other:

Any known health issues or limitations?
Yes No

Currently taking any medications?
Yes No

Can camper self-administer medication?
Yes No

If needed, may camp directors administer pain medication?
Yes No Other:

Medical Insurance Do you have medical insurance?
Yes No

Insurance Company:

Policy Number:

Insurance Phone Number:

Primary Policy Holder's Name:

First Aid & Consent Agreement

I authorize Heritage Youth Camp staff to seek emergency medical treatment if needed. I assume full responsibility for costs incurred. I also agree to follow all camp rules and hold Heritage Youth Camp harmless in the case of injury or illness due to my own actions.

I agree to the terms above

E-Signature:

Date:

Camper Registration

Camper Information