Summer Camp Pre-registration Form

Registration Fees will be paid through PayPal and must be completed in order to complete registration process online. YOU DO NOT need to have a PayPal account to use this system and may use credit card or debit card. If you do not have a Paypal account you may sign in as a "guest".
Only one camper may be registered at a time.
Camper's Full Name*
First NameLast Name
Address*
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Birth Date*
MonthDayYear
Current Age:*
Gender:*
MaleFemale
Phone Number*
Area CodePhone Number
E-mail Address where you'd like to receive confirmation and information:*
Camp Session camper is registering for:*
Grade Entering Fall 2012*
What church do you attend:
Please provide at least 2 emergency conacts.
1st Emergency Contact Name*
First NameLast Name
1st Emergency Contact Relationship:*
1st Emergency Contact Daytime Phone Number:*
Area CodePhone Number
1st Emergency Contact Evening Phone Number if different:
Area CodePhone Number
2nd Emergency Contact Name:*
First NameLast Name
2nd Emergency Contact Relationship:*
2nd Emergency Contact Day Phone Number:*
Area CodePhone Number
2nd Emergency Contact Evening Phone Number if different:
Area CodePhone Number
Please list other important emergency contacts, their relationship to camper, best phone numbers or other contact information that will be helpful in an emergency.
Doctors Name or Medical Clinic:*
Doctor's Phone Number:
Area CodePhone Number
List any medical food allergies: (If none, enter none)*
List any chronic illness and or physical limitaitons camp should know about: (If none, enter none)*
Date of last tetanus shot:*
List all current medications: (If none, enter none)*
Is camper covered by medical insurance:*
YesNo
Name of Insurance Company (enter none if no insurance):*
Policy Number (enter none if no insurance):*
I, as the registered am 18 or over, or I am a parent or legal guardian of the registered who is currently under the age of 18, grant permission for the registered camper to attend Camp Utmost and consent to its Discipline Policy and also do hereby release Camp Utmost and Rocky Mountain Bible Mission from any and all liability or responsibility due to any injury that he/she/I may incur as the result of, or arising in any way from participation in activities at or under the direction of Camp Utmost. I am fully aware and consent to accept these risks and voluntarily agree to allow his/her participation in activities. If I cannot be consulted in an emergency, I hereby give permission to the physician selected by a representative of Camp Utmost to hospitalize, secure treatment for, and to order injections, anesthesia, and/or surgery for the person named above. I understand that Camp Utmost only carries secondary insurance and that I will take primary responsibility for any fees or charges at any clinic, facility, or hospital arising from treatment of injury or illness. I furthermore understand Camp Utmost often takes photographs or videos of participants during its activities or events. I grant permission without compensation that these photographs or videos may be used in publications, presentations, websites or promotion of Camp Utmost or Rocky Mountain Bible Mission. Camp Utmost will not identify me or my child by name, or release any other personal information without additional written permission from me.
Electronic Signature: By entering my name below, I accept the above conditions and releases. (You must be 18 years old or over to sign below.)*
First NameLast Name
Relationship to registered camper:*
Current Date:*
MonthDayYear
Click Only One Camp Session. Camp rates increase $10, 10 days before each camp starts. Optional Items are also listed. You may also pay for bus transport, add funds to camp store, pre purchase products or make a donation.*
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Utmost 8th & 9th Grade, June 18-23 (Regular Registration Rate)$100.00

Utmost 6th & 7th Grade Boys, June 25-29 (Early Registration Rate)$90.00

Utmost 6th & 7th Grade Girls, July 9-13 (Early Registration Rate)$90.00

Utmost 4th & 5th Grade Boys, July 16-20 (Early Registration Rate)$90.00

Utmost 4th & 5th Grade Girls, July 23-27 (Early Registration Rate)$90.00

Utmost High School Camp (10th - Grad. 2012), July 27-30 (Early Registration Rate)$75.00

Bus Transport (Stops in Lolo, Missoula & Bonner). Round trip or one way is the same fee.$10.00

Bus Stop Location

Add Funds To Camp Store Account (check box and choose an amount)$1.00

Check $ amount to add

Purchase 2012 T-Shirt$12.00

Purchase Metal Utmost Logo Water Bottle$10.00

Purchase Plastic Utmost Logo Water Bottle$5.00

Purchase Stainless Steel Utmost Logo Travel Mug$7.00

I would like to make a donation to help a another camper be able to attend Camp Utmost$1.00

Check Amount of Donation

Total $0.00
For Security, type the message seen below:*
An 80% refund of camp fee is made if notice is given to Camp Utmost by the early registration deadline of that camp. A 50% refund is made if notice is given to Camp Utmost no later than the beginning of that camp. No refund will be made once the camp starts. Canceled online store deposits and merchandice purchases will be refunded at 95% to compensate for fees Camp Utmost has to pay.
All refunds are processed after the camp ends. We do not prorate fees for attending only a part of the camp week.
Upon completion of filling in all areas of form, click "Submit Form". You will then be taken to PayPal where you will pay and registration process will be completed. Only one camper may be registered at a time. You may click "Print Form" to print a copy of this form. Please also print "Camper/Parent page for needed information.Do you have questions or need help with online registration? Email Lloyd at camputmost@gmail.com.
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