Register for Summer Camp

Ready to register for camp? Fill out the form below or download and mail your registration form.

Name *

Gender *MaleFemale

Age *

Date of Birth *

Month *

Day *

Year *

Email Address *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country

Phone *

Parent / Guardian *

Emergency Contact Name *

Emergency Contact Phone *

Relationship of Emergency Contact *

Pickup Person *

Church *

Date of Last Tetanus Shot

Do you have insurance? *YesNo

Insurance Provider *

Name of Policy Holder *

Policy Number *

Are you Current on Immunizations? *YesNo

Dietary Needs

Allergies

Medications

Do you have any of the following? *YesNo Sleepwalk, Faint, Epilepsy, Diabetes, Asthma

Do you Sleepwalk *YesNo

Do you Faint *YesNo

Do you have Epilepsy *YesNo

Do you have Diabetes *YesNo

Do you have Asthma *YesNo

Pre Existing Medical Conditions

Other Important Information

OnlineMailWhen you arriveI have a full schoarship

I Agree

Type Name as Signature *Parent or Guardian if under 18