Sunshine Church of Christ Youth Rally
Please fill out one copy of this page for each member of your group.
Date of youth rally_______________________________
Name ______________________________________________________________
Age______ Sex ______
Name of group/church ___________________________________________________
Name of group's counselor/chaperone _________________________________________
Contact in case of emergency:
Name______________________________
Relationship ___________________________
Daytime Phone________________________
Evening Phone_________________________
Medical Insurance _____________________________________________________________
Insurance Identification Number __________________________________________________
Employer through which insurance is received ________________________________________
Known allergies/medical conditions ________________________________________________
Describe reaction and indicate medication used _______________________________________
Is there any type of activity restriction? ____
If yes, please explain _____________________________________________________________
_____________________________________________________________
Any other information?
Assigned to cabin #___________