Victory Bible Camp

PARTICIPANT INFORMATION

Full Name: _______________________________________________________________

Date of Birth: _____________________________________________________________

Parents/Guardians Names: ___________________________________________________

Home Phone #: ______________________School Grade: ___________________________

Address: _________________________________________________________________

Father’s Place of Employment: ____________________Work Phone #: ________________

Mother’s Place of Employment: ____________________Work Phone #: ________________

Medical Insurance Company: ___________________________Phone #: ________________

Policy #: ___________________________ Group #: _______________________________

Family Physician: ___________________________________ Phone #: ________________

MEDICAL HISTORY INFORMATION

Past Medical Problems: ______________________________________________________

Medication Currently Taking: _________________________________________________

Surgeries: ________________________________________________________________

Drug/Food Allergies:_________________________________________________________

Are you allergic to insect bites? _____YES _____NO. If so, what reaction: _______________

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Are you allergic to insect stings? _____YES ____NO. If so, what reaction: _______________

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Last date DPT shot: ___________________ Last date tetanus shot: ____________________

List any physical limitations we need to know about: _________________________________

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