Fall Creek
Christian Campground
CHRISTIAN YOUTH CAMP
and YOUTH RETREATS
423-881-5400
ChristianCampground.com P
O Box 717, Pikeville TN 37367
~ MEDICAL INFORMATION ~ CAMPER'S NAME: _______________________________________________
AGE: _____________________ CHILD'S FAMILY DOCTOR: __________________________________
PHONE: ______-______-___________ EMERGENCY
NUMBERS OF PARENTS OR GUARDIANS: Father’s name: _________________________
Mother’s name: _________________________
Home: ______ / ______ / ______________
Home: ______ / ______ / ______________
Mobile: ______ / ______ / ______________
Mobile: ______ / ______ / _____________
Work: ______ / ______ / ______________
Work: ______ / ______ / ______________
Other: ______ / ______ / ______________
Other: ______ / ______ / ______________
ALLERGIES: _______________________________________________________________________________
MEDICATION:
DOSAGE:
FREQUENCY: ______________________________ ____________________
__________________________
______________________________ ____________________ __________________________ ______________________________
____________________ __________________________ ______________________________ ____________________
__________________________
______________________________ ____________________ __________________________ IF CAMPER HAS REACTION,
EXPLAIN HOW IT AFFECTS THEM AND WHAT SHOULD BE DONE. __________________________________________________________________________________________ DATE OF LAST TETANUS
SHOT: _______________ ARE SHOTS UP TO DATE? ______________________ DOES CAMPER HAVE
ANY PROBLEM THAT STAFF SHOULD BE AWARE OF? If so, please explain. __________________________________________________________________________________________ PERSON PICKING
UP CAMPER AT END OF CAMP: ______________________________________________ NAME OF CAMPER'S HEALTH INSURANCE
CO: _________________________________________________ TELEPHONE #: ______-______-________
INSURANCE CARD #: ____________________________________ WILL CAMPER HAVE HEALTH INSURANCE CARD __________________ or COPY? ____________________ As the parent or guardian,
I give my permission for my child to receive emergence medical treatment for accident or illness. ________________________________________ DATE: ______/______/____________SIGNATURE OF
PARENT (S) OR GUARDIAN
Medical permission
is in effect for a period of one year from date.
FCCC-111 (06/11) 
