Camper’s Name:
Parent / Guardian Information
Father’s Name
Address Same as Camper / Different
City State zip code
Home Phone Cell Phone
Work Phone Email
Mother’s Name
Address Same as Camper / Different
City State Zip Code
Home Phone Cell Phone
Work Phone Email
Emergency Contact
Name (other than parent/ Guardian)
Relationship
Home Phone Cell Phone
Health Provider
Insurance Company
Insurance Company Phone Number
Insured’s Name
Insured’s Date of Birth Policy Number
Camper Information
Name
Address
City
State Zip Code
Home Phone Male / Female
Date of Birth Age: Grade Entering
Church You Attend Immersed (Baptized) Y/ N
Swimming Information
My child knows how to swim (Please choose one)…
My child has my permission to swim at camp and on outings
yes/no Date
Medical Information
Date of Last Tetanus Booster Vaccines up to Date Y / N
Name All Allergies
Check each your child is not allowed to receive:
My child has the following conditions (check any that apply)
List other medical conditions:
Medications
All medications must be brought in the original container with the current dosage correctly printed on the bottle. All medications must be turned in at the time of registration.
NO EXCEPTIONS
Name all of Medications
and reasons for taking;
and list the dosage for
each medication.
Week You wish to attend
Age Group
Date
Date Church Paid Scholarships
If your church is willing to pay for all or part of your camp fee, please enter the amount being paid and have list the name and phone number of the minister who has agreed to do this.
Amount: $ Name of Minister
Please Note that when you click submit at the bottom you are agreeing to the Waiver of Liability in this next section:
Risk of Injury/Waiver of Liability
I give my permission for my child to participate in recreational, swimming, and learning
Activities, and to be bound by all camp policies in force.
I desire that my child participate in the full range of camp activities and acknowledge the natural condition of the camp and the interactions with other children of various ages may subject my child to risk of injury on and off the camp premises.
I therefore release the camp from any responsibility other than normal supervision and care. In case of accident, I will not hold Smoky Mt. Christian Camp, its staff, management, faculty, volunteers, or officers liable. Further I waive any and all claims or causes of action against the foregoing parties which may arise as a result of an accident or an injury to my child at Smoky Mountain Christian Camp.
In case of emergency, I hereby give permission to the physician selected by the camp management or dean to secure proper treatment for my child as named on this form. Doctor calls, treatment or hospitalization are to be charged to our family insurance.
I understand that Smoky Mountain Christian Camp and its staff should not be held responsible for any articles lost, stolen, or left at camp.
I give my permission to leave camp grounds for various service or fun related activities under the supervision of an adult faculty member. I will not hold Smoky Mt. Christian Camp responsible for any injuries that may occur while away from the camp.
By registering my child in the programs of Smoky Mountain Christian Camp, I give my consent for the camp to use my child’s photograph in camp promotion and publicity.
Method of Payment
In order to register you need to at least pay a $25 registration fee. Use paypal even if you don't have a paypal account; you can use a credit card on paypal. Submit this form first and then come back and pay by paypal. If you are writing a check please make it out to SMCC and send to Smoky Mountain Christian Camp, P.O. Box 116, Coker Creek, TN, 37314
Pay Method:
How Much are you paying now: Amount: $
Submit form
If paying by check what is yourCheck #: before using
paypal
Paypal reads "donate" beside
here because that button allows
you to put in whatever amount you
want, so feel free to make any
payment toward the week of camp
that you want right now.
Please leave any other comment or let me knowif you had trouble with anypart of registration.Please note we this is not a secure site. We are trying to make it secure and your payment is secure by using paypal.
