Application

The Sam Davis Youth Camp - 2008 Registration Form

Full Name: ____________________________________________________________

Street Address: ____________________________________________

City: ______________________ State: _______ Zip Code: __________

E-Mail Address: ______________________________________    

Gender: ______ Male ______ Female

Date of Birth:  (must be born on or before June, 1996)
_______________________________________

Which SD Youth Camp will you be attending?   _____ Texas  _____ Georgia

Name of Sponsoring SCV Camp: ________________________________________________________

Parent or Guardian with Whom Camper Lives:  _____________________________________________

Parent/Guardian Work or Emergency Contact Phone Number:  _________________________________

Required Medical Information

Please attach additional information as needed.

Date of Last Tetanus Booster:  ___________________________________________________________

Prescribed Medication Taken, if any:  _____________________________________________________

Reason for Taking Medication: __________________________________________________________

Specific Allergies (including type of reaction):  _____________________________________________

_____________________________________________

Does Camper Have Asthma or Hay Fever? _________________________________________________

Specific Activities to Be Restricted (Please state reason): 
_____________________________________

_____________________________________

Insurance Information (Group, Plan Number & Phone Number).  Please attach copy of Insurance Card

_________________________________________________________________

Medical Release Form

Registration cannot be processed without the signature of the camper’s parent or guardian on this release form.

In case of medical emergency, I understand every effort will be made to contact parents or guardians of campers.  In the event that I cannot be reached, I hereby give permission to the physician selected by the Sam Davis Youth Camp to hospitalize; secure proper treatments; and order injection, anesthesia, or surgery for my child as named.  I also understand that the Sam Davis Youth Camp reserves the right to review any information given and determine camper capability based upon that information.

Parent or Guardian’s Signature: _________________________________

Date: ___________________

Payment Information

 Payment is due when your completed application is submitted.  The cost for room, board, and all activities and needed supplies is $495.00 for each camper.  Make checks payable to The Sam Davis Youth Camp, and mail to: Post Office Box 59, Columbia, TN, 38402.  When your registration has been received and processed, you will receive a confirmation by mail, followed by details regarding camp facilities and scheduled activities.  

Registration Deadlines:  June 23, 2008 Texas and July 21, 2008 Georgia