GBC Youth Camp

Name:___________________________________    Male___ Female___
City: __________________________    State: ______    Zip:________
Phone: ( _____ )___________________    Age: ______

Medical Allergies, medicine being taken, medical problems, or other pertinent medical information:  ______________________________________________________________

Name of major Medical Insurance Carrier:

Policy Name Holder’s:                             Policy Number:
______________________________    ______________________________

“I (We) understand that in the event medical treatment is required, every effort will be made to contact me.  I give my permission to the staff to secure the services of a licensed Physician to provide the care that is necessary, including anesthesia, for my child’s well being.  It is agreed that the camp sponsors or directors will not be responsible for injuries by accident or otherwise.  I (We) also understand that our child MUST OBEY ALL RULES as set forth by the camp directors.”

________________________________        Date: ______________
Signature of parent or guardian
Phone: ( _____ )___________________

Young people going into the 7th grade through 19 years old are eligible for registration.  Camp fee is $85.00 if registration form is mailed by May 21st.  For registrations received after this date the camp fee is $100.00   Forms can be given to your youth leader or sent to

Scott Miller : GBC Youth
P.O. Box 49  
Seaman, OH 45679
Ph. (937) 386-2058