Trinity Baptist Church

Registration form #2 for "His Kids Day Camp"

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First Name Last Name
Address
Address Line 2
City State Zip Code
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First Name Last Name
Email Address
Address
Address Line 2
City State Zip Code
Phone Number
Phone Number



Select all that apply
Heart Disease/Heart Defect/High Blood Pressure
Chest Pain
Seizures/Epilepsy/Fainting Spells
Diabetes
Concussions or serious head injury
Major Surgery or serious illness
Heat Stroke/Exhaustion
Blindness/Visual Problem
Contact Lenses/Glasses
Hearing Loss/Hearing Aid
Bone Or Joint Problem
Asthma
Easy Bleeding/History of Blood Disorders
Emotional/Psychiatric/ Behavior
Immunizations up to date
Other


* required