Application and Liability Release

Name _________________________________________  Age_________

Address _______________________________________          

City      _____________________State ______ Zip Code _____________

Telephone Day________________ Telephone Night_________________

Allergies_________________________________________

Doctor's Name/Phone Number_____________________________

Insurance Policy Information______________________________

Emergency Phone Number________________________________

Pastor's Name/Phone Number_____________________________

I give the administration of Camp Canaan and Pastor Noah Broughton permission to seek medical attention for my child.

Parent's Signature_____________________________________    

Date__________________