Participant Registration & Release Form

4341 FM 356 | Trinity, TX 75862 | 936-594-5011 | TrinityPines.org

Participant Full Name* Mailing Address*

City* State* Zip*

Birth Date* Age* Sex*

Home Phone* Name of Church or Group

Church City Church State

Parent/Guardian (If Attendee is a Minor)

Name Relationship to Camper Parent/Guardian Email Parent/Guardian Phone (Day)* Parent/Guardian Phone (Evening) Parent/Guardian Phone (Other)

Emergency Contacts

Contact 1 Name* Phone* Relation

Contact 2 Name Phone Relation

Medical Information

Diseases, Chronic or Recurring Illness Allergies By checking, I give permission for the Camp Health Supervisor to give standard over-the-counter medication as needed (acetaminophen, ibuprofen, etc.) Exceptions to medication permission

I have read and agree to the Participant Waiver & Release. Signature of Participant (type name)* Date* Signature of Parent/Guardian (if minor, type name) Date