2017 Youth Camp - July 10-14,  - Registration - DUE MAY 21, 2017
 
2017 Youth Camp - July 10-14, - Registration - DUE MAY 21, 2017
Student First Name  * 
Student Middle Initial  * 
Student Last Name  * 
Student Date of Birth (MM, DD, YY)  * 
Student Age  * 
Student Gender  * 
Student Mailing Address - NUMBER and STREET  * 
Student Address - CITY  * 
Student Address - STATE  * 
Student Address - ZIP  * 
Parent/Guardian Name (First and Last)  * 
Parent/Guardian Phone Number  * 
Your Email Address  * 
Alternate Emergency Contact Person  * 
Alternate Emergency Contact Phone Number  * 
Emergency Contact’s Relationship to Camper  * 
If Camper will be leaving camp EARLY, and leaving with someone other than the group leader, please list the name of the person picking them up and the reason why.
List anyone you know who may claim the right to sign your child out of camp, but to whom they should NOT be released? (Please list their complete name(s) on this form).
Does the Camper have any allergies?  * 
If so, please explain
Please list the last year your child had the Tetanus Toxoid immunization  * 
Can the nurse give Tylenol to your child?  * 
Has your child had any of the following?
Measles  * 
Polio  * 
Mumps  * 
Chicken Pox  * 
Scarlet Fever  * 
Whooping Cough  * 
Please list any other communicable diseases the camper has had
Does the camper have any of the following medical conditions:
Heart Trouble  * 
Ear Trouble  * 
Asthma  * 
Hernia  * 
Sleepwalking  * 
Please explain if you answered "yes" to any of the above, or use this space to provide us with information on any other medical conditions of the camper of which we should be aware.
This form will allow you to pay the per camper cost of $200, or $100 deposit today (due May 21) and the remaining $100 by JUNE 4. If cost is an issue, please speak with Ms. Nicole
Registration Payment Options  * 
The following are other options you can add to your registration. Again, these are options, but not required. However, if you do not order them now, they will not be available later.
Camp T-Shirt  * 
Camp Highlights DVD  * 
Snack Shack Pre-Paid Card  * 
Any comments/questions
Total $
 
 
Online Giving Powered by Easy Tithe