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Health Form (must be completed to come)

Emergency Contact_______________________________Phone________________________

Does your camper have any allergies to medications, foods, molds, insects, etc?________ If yes, what are they and how do they react?___________________________________________________________________

Medications presently taking (name, dose, time)_________________________________________________

Immunization History: Diptheria-Tetnus:______Date_______ Polio: _______Date______

Diet Restrictions:_______________________________________________________

Any discouraged activities?_______________________________________________

Insurance Company_______________________ Policy or Group #_______________

Address_________________________________ Phone (___)_______________

In case of medical emergency: I give my permission to the camp Health Care Manager to treat my child for minor aches, flu-like symptoms, rashes, and injuries with medications approved by the camp's local physician. I give my permission to the local physician to hospitalize, treat, medicate, or perform surgery for my child if I or an alternate cannot be reached.

Signature (adult)_____________________________________Date_______________

2005-2006 Retreat Registration Please check the retreats that you are registering for at this time. Each retreat checked requires a $15 deposit --- (ex. Septoberfest and Youth Faith Film Fest would be a $30 deposit)
Septoberfest_____3-6 grade Youth Faith Film Fest_____7-12 grade	Winter Fun Day _____Grades 3 and up	Mini Camp Day_____2-3 Grade March Madness_____ 3-6 grade
All information must be filled out to register. Check the other web pages for due dates on registrations Name______________________________________________Grade_____ Gender M or F Address_____________________________________________ City________________ State____Zip_______ Congregation_______________ Cabin mate (please limit to 1 or 2)______________ Email_______________________
Please return completed registration, health form, and deposit to Shetek Lutheran Ministries Youth Retreats, 14 Keeley Island Drive, Slayton, MN, 56172-----Balance due upon arrival to camp--------Phone # 507-763-3567---------Email: slbc@frontiernet.net

============================================================= Health Form (must be completed to come) Emergency Contact_______________________________Phone________________________ Does your camper have any allergies to medications, foods, molds, insects, etc?________ If yes, what are they and how do they react?___________________________________________________________________ Medications presently taking (name, dose, time)_________________________________________________ Immunization History: Diptheria-Tetnus:______Date_______ Polio: _______Date______ Diet Restrictions:_______________________________________________________ Any discouraged activities?_______________________________________________ Insurance Company_______________________ Policy or Group #_______________ Address_________________________________ Phone (___)_______________ In case of medical emergency: I give my permission to the camp Health Care Manager to treat my child for minor aches, flu-like symptoms, rashes, and injuries with medications approved by the camp's local physician. I give my permission to the local physician to hospitalize, treat, medicate, or perform surgery for my child if I or an alternate cannot be reached. Signature (adult)_____________________________________Date_______________