* = required field
Event Attending
*
Contact Information
Camper Father
(or primary
guaridan) 		Mother
(or secondary
guardian) 		Emergency
Contact
(not parent/guard.)
Relation-
ship 		Self
*
*
First Name
*
*
*
Last Name
*
*
*
Address Same As Camper?
No
Address
*
*
*
City
*
*
*
State
*
*
*
Zip
*
*
*
Home
phone
*
*
*
Work
phone
*
*
Cell
  
Email
*
Send email
confirmation?
Yes
Camper Information
Gender*
Date of birth*
Grade entering*
Church you attend*
Camper immererced/baptized?
My child has my permission to
swim at camp and on outings*
My child knows how to swim*
Insurance Information
Policy holder*
Insurance company*
Insurance company phone*
Insured's date of birth*
Policy ID#*
Policy group #*
Medical Information
Date of last tetanus booster*
Vaccines up to date?*
Not allowed Tylenol
Not allowed Bendryl
Not allowed Ibuprofen
Other medicines not allowed (allergic)

All medications must be brought in the original container with the current dosage correctly printed on the bottle. All medications must be turned in at the time of registration. NO EXCEPTIONS
Check all that apply:
Asthma
Epilepsy
Sleepwalk
Diabetes
Migranes
Heart Disease
Seizures
ADD / ADHD
Pennicillin allergy
Hay fever
Bee sting allergy
Ear infections
Posion Ivy allergy
List any other medications, dosages, medical conditions & medical related instructions
Scholership & Payment Information
If your church is willing to pay for all or part of your camp fee, please enter the amount being paid and have list the name and phone number of the minister who has agreed to do this.
Minister granting scholarship
Church scholership amount ($)
Risk of Injury/Waiver of Liability
Please Note that when you click submit at the bottom you are agreeing to the Waiver of Liability in this next section:

I give my permission for my child to participate in recreational, swimming, and learning Activities, and to be bound by all camp policies in force.

I desire that my child participate in the full range of camp activities and acknowledge the natural condition of the camp and the interactions with other children of various ages may subject my child to risk of injury on and off the camp premises.

I therefore release the camp from any responsibility other than normal supervision and care. In case of accident, I will not hold Smoky Mt. Christian Camp, its staff, management, faculty, volunteers, or officers liable. Further I waive any and all claims or causes of action against the foregoing parties which may arise as a result of an accident or an injury to my child at Smoky Mountain Christian Camp.

In case of emergency, I hereby give permission to the physician selected by the camp management or dean to secure proper treatment for my child as named on this form. Doctor calls, treatment or hospitalization are to be charged to our family insurance.

I understand that Smoky Mountain Christian Camp and its staff should not be held responsible for any articles lost, stolen, or left at camp.

I give my permission to leave camp grounds for various service or fun related activities under the supervision of an adult faculty member. I will not hold Smoky Mt. Christian Camp responsible for any injuries that may occur while away from the camp.

By registering my child in the programs of Smoky Mountain Christian Camp, I give my consent for the camp to use my child’s photograph in camp promotion and publicity.

Payment Information
In order to register you need to at least pay a $25 registration fee. Use paypal even if you don't have a paypal account; you can use a credit card on paypal. Submit this form first and then come back and pay by paypal. If you are writing a check please make it out to SMCC and send to Smoky Mountain Christian Camp, P.O. Box 116, Coker Creek, TN, 37314
Total amount due
How much are you paying now? ($)*
Payment method*
Please leave any other comments or let me know if you had trouble with any part of registration.