Southern Florida District Teen Camp 2017 - Student Registration
June 12-16, 2017 at LPC3 (Lake Placid Camp & Conference Center) Cost: $175.00 (before May 28th), $200.00(May 29 - Until Camp) (6th-12th grade)
First Name
*
Last Name
*
Address
*
City
*
State
*
Zip
*
Home Phone #
*
Your Email Address
*
Guardians Names:
*
Parent Cell #
*
School Grade Completed
*
Birthday (mm/dd/yyyy)
*
Sex
*
Male
Female
What church do you attend?
*
Youth Leader at Local Church
*
T-Shirt Size
*
S
M
L
XL
2XL
3XL
INSURANCE AND MEDICAL INFORMATION Please list any medical issues, past or present, that the event staff needs to be aware of:
Allergies:
Past Surgeries:
Name of medications & dosage the student will be taking:
Medications the student is allergic to:
Insurance Company and Policy #
*
Emergency Contact / Relationship
*
Emergency Contact Phone:
*
I hereby give authority to Brad Ives NYI District President to obtain necessary medical attention or to authorize treatment at any hospital in the event of a medical emergency.
*
No
Yes
Original notarized registration needs to be turned in during Check-in. I will bring the form:
*
No
Yes
Send us an email, if you have any other questions: NYITeenCamp@sfnazarene.org
Payment options: Pay with credit card or have your church send a check to Brandt Brantley, 815 North Homestead Boulevard, #121 , Homestead, Florida 33030
*
Church will send a check
Student (Add $200.00)
Regular registration (until Sunday, May 28th)…$175/student | Late Registration (Monday, May 29th until camp)…$200/student
Total
$
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