West Metro Church of Christ Camp Registration 2025

Camp Inagehi
2214 Camp Inagehi Rd, Douglasville, GA 30134
Ages 8-18

Name

Address

Date of birth

Age at time of camp

Sex

Please select one option.

Male Female

Shirt Size

Please select one option.

YS YM YL S M L XL XXL

Home Church

Father's Name

Mother's Name

Legal Guardian (if different from above)

Home Phone

Mobile Phone

Work Phone

This address will receive a confirmation email

Parent Employer

Employer Phone

Primary Insurance Carrier

Insurance Policy Number

Insurance Group Name/Number

Emergency Contact

Phone

Relationship

Alternate Emergency Contact

Phone

Relationship

Please list any medications your child will need to take while at camp along with the frequency and dosages. (All medicines must be in original containers and clearly labeled. All medicines must be left with the nurse at registration.):

Please indicate over-the-counter medications that you will allow the nurse to administer to your child:

Please select all that apply.

Tylenol Sudafed Ibuprofen Cough Medicine Mylanta Benadryl None

Please list any medications your child is allergic to:

Please list any other known allergies your child has (foods, bee stings, etc.):

Please list any special dietary needs:

Please list anything else we need to be aware of (phobias, bedwetting, etc.):

Are your child’s immunizations up to date?

Please select all that apply.

Yes No

Date of last tetanus shot

I, the undersigned parent or legal guardian, appoint the Camp Director and his staff as my agent to, in the event of sickness or injury: 1. Administer minor medical emergency aid or treatment which they deem appropriate for my child. 2. Give consent to any emergency medical procedures, tests, or treatments for my child which they shall deem appropriate under the circumstances.

Please select one option.

Yes No

Name

Date

Payment

(160.00) Pay Later ($0)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

Camp Inagehi
2214 Camp Inagehi Rd, Douglasville, GA 30134
Ages 8-18

West Metro Church of Christ Camp Registration 2025

Description

Please Fix the Following