Men's Retreat Registration and Medical Release 2026

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

Please Note: State law requires all medications, OTCs, and supplements be turned over to the camp nurse. Prescriptions must be in the original container, labeled with the prescription, including the participant’s name and dosage instructions. Supplement and over-the-counter (OTC) medications must be in the original sealed container with the participant’s name on it. OTC medications such as Tylenol, Motrin, Sudafed, Benadryl, Acetaminophen, Ibuprofen, Pseudoephedrine, and Diphenhydramine may be available from the camp nurse as needed. Questions regarding the above should be directed via email to the camp director. The following OTC medications are not to 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.

Date Signed

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 2026

Description

Please Fix the Following