Registration Form JBC

Last Name *

First Name *

Birthday *

Gender *

Postel Code *

Address (Apt #/name, Street, City & Prefecture) *

Parent/Guardian Name *

Full time Christian worker *

Yes

No

Cell Phone *

Home Phone

Work Phone

Email *

Name 1 *

Relationship

Cell Phone *

Name 2 *

Relationship

Cell Phone *

Is your child enrolled in Japanese National Health Insurance *

Yes

No

Other insurance or explanation of coverage

Any Special Medical Conditions or Concerns *

Yes

No

Specify medical conditions

Medication Taken Daily *

Yes

No

List of medications and times to be taken

Any allergies *

Yes

No

Explanation of allergies

Restricted Activity (Is this camper to be restricted from an activity?) *

Yes

No

Explanation of restricted activity

Has had the tetanus immunization vaccine *

Yes

No

Tetanus immunization date

Do you have any serious concerns about the above questions? *

Yes, I want to talk to the kitchen staff.

Yes, I want to talk to a camp nurse.

No, not necessary.

Explanation of concerns

Arrival *

Arrival by CAR to OBC between 3pm and 3:30pm

Arrival by TRAIN (PLEASE NOTE CAMPERS GO DIRECTLY TO OBC)

Departure *

Departure by CAR picking up child from OBC between 2pm and 2:30pm

Departure by TRAIN (PLEASE NOTE THERE WILL BE NO STAFF WITH CAMPERS)

Note to OBC

Release of Liability and Requested Permissions

Check here if you accept these terms.

Fall / Winter

Spring

Summer