Men's Retreat Registration and Medical Release 2025

Name of Camper (and Parent if Minor)

Address

This address will receive a confirmation email

Phone/Cell

Date of Birth

Church Association

Start and End Date of Camp

Emergency Contact

Health Insurance Provider and Medical Record Number

Immunizations Current?

Yes No

Date of Last Tetnus

Medical Conditions, allergies, drugs

Parents please note: If your child requires medications while at camp, the following policy and procedure will be followed: 1. All medications will be turned into the camp nurse at registration. This is a state law. This includes prescriptions, supplements and over-the-counter (OTC) medications. 2. Prescriptions must be in the original container, labeled with the prescription, including camper's name, date of birth, current dosage and frequency. This includes inhalers and epi-pens. 3. Supplements and OTC medications must be in the original sealed container with the campers name on it. The camp usually provides OTC basic meds such as Tylenol, Motrin, Sudafed, Benadryl, Acetaminophen, Ibuprofen, pseudoephedrine, diphenhydramine. They are available from the nurse as needed. 4. Anything brought to camp that does not comply with the above procedures will be stored with the nurse and returned at the end of camp. 5. Questions regarding the above policy may be directed to the directors email and will be forwarded to the camp nurse. Please list the OTC medications which may NOT be given

List activity restrictions

I understand that Pilot Lake (Regular Baptist Camp, Inc.) does not provide medical coverage, nor reimburses for medical expenses that may arise from illness or injury while at Pilot Lake, and that my insurance may be charged for medical services performed. I give my permission for myself or my child to receive any medical or dental attention deemed necessary because of such illness or injury. Furthermore, I give permission for any quotes or pictures of myself or my child taken during camp to be used by Pilot Lake for promotional purposes. I hereby release Pilot Lake (Regular Baptist Camp, Inc) and its staff of any liability. I understand every effort will be made to contact those listed above. I also give the above camper permission to attend and participate at Pilot Lake.

Please state your acknowledgment of these policies and procedures.

Cost: Adult - $160 | Child (under 18) - $140

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

Please fill out this Pilot Lake Medical Release Form and click submit.

Men's Retreat Registration and Medical Release 2025

Description

Please Fix the Following