2024 MLBC Health and Medical Release Form for High School Camp
Please fill out this form and click submit.
Camper Name
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Camper Date of Birth
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Emergency Contact Name
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Emergency Contact Phone
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Emergency contact Relationship
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Secondary Emergency Contact
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Secondary Emergency Contact Relationship
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Secondary Emergency Contact Phone
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Physician Name
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Physician Phone
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Insurance Co.
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Insurance Member ID #
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Health Concerns
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List any medications the camper SHOULD NOT recieve
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Waivers for Mountain Lakes Bible Camp (MLBC)
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Please select all that apply.
By checking this box certify that it is my intention that I, and any family members attending with me, plan to participate fully in the selected camp program. I verify that the above information is complete and accurate to the best of my knowledge.
By checking this box I verify that all Immunizations are up to date for myself and my children (if applicable) who are attending a sponsored camp at MLBC.
By checking this box I hereby grant permission for my myself or child (where applicable) to receive first aid and emergency treatment by camp personnel in the event of illness or injury, or by the hospital emergency room in case I cannot be reached.
Checking this box voluntarily waives any claim against MLBC, camp personnel, or persons transporting my child, against all liability, claims, damages, attorney fees, or expenses arising out of or in connection with any activities of the above organization
By checking this box I certify that I give permission for myself and/or my child’s photo or image to be used in any media presentation for MLBC or Bible Baptist Church.
By checking this box i certify that I agree to notify MLBC of any changes prior to the camp session.
Signature*
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*By entering my name in the box above, I am providing my digital signature on this form.
Submit
Description
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