Mini-Camp Registration Form

Name*

First NameLast Name

Gender*

MaleFemale

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone*

Area CodePhone Number

Emergency Contact Name*

First NameLast Name

Emergency Number*

Area CodePhone Number

Emergency Number #2

Area CodePhone Number

Birth Date*

MonthDayYear

Year of Graduation*

Grade entering in the fall*

Cabin Buddy #1

Cabin Buddy #2

Parent/Legal Guardian*

First NameLast Name

Relation*

Work Phone*

Area CodePhone Number

Cell Phone

Area CodePhone Number

Parent /Legal Guardian 2

First NameLast Name

Relation 2

Work Phone 2

Area CodePhone Number

Cell Phone 2

Area CodePhone Number

Church you attend

Church City

Church you are coming with (if any)

Parents Email (camper confirmation will be sent by email, if left blank it will be mailed)

Camper's Email

How did you hear about us?

First Time Camper? (If yes, subtract $25 from camper fee)*

YesNo

It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. If the information has changed on the day of registration please see the health officer at that time. Please bring all medication in ORGIANAL CONTAINER or you will not be allowed to leave the medication or vitamins at the camp. No exceptions. All prescriptions must be in that campers name and the correct dosage.

Is camper free from infectious desease or conditions?*

YesNo

Are immunications up to date?*

YesNo

Date of last tetanus shot*

All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.

Any activity the camper should be restricted from?*

Any physical, mental or other condition that would require special attention or medication while at camp?*

List any past medical treatment that would be helpful for us to know.*

List any allergies (ex: bees,peanuts, dairy)*

Any dietary needs that we should know about?*

List all medications, both prescribed and over the counter, all medications will be turned into the health officer except rescue inhalers, bring all medication in original containers.*

Method of Payment*

(Paypal or Credit Card)Registration Fee+Processing Fee$51.50

Send a Check $50 (No Processing Fee)$ Free

If paying with PayPal you will be redirected to PayPal once you hit submit. You can either pay with credit card, or PayPal. There is a $1.50 processing fee for using this option. The remaining balance is due anytime before their week of camp.

If paying with a check, please send the registration fee as soon as possible. You can pay multiple registration fees with one check. In memo, please put the camper(s) name. The remaing balance is due anytime before their week of camp.

Camper Release (List anyone, including parents, to whom your camper can be released)*

Be certain to enter your email address correctly on the registration form to receive confirmation via email with in 2 weeks

By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above named camper, and are over the age of 18. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named camper by authorized personnel. The camp carries secondary insurance. I understand that the above named camper will only be released to the names listed above, an update may be done at registration. I certify that my child has my permission to attend camp and participate in all activites. I authorize The SUMMER SCHOOL to use my camper's picture, testimony, and video in any promotional material(web,print,or media) My child may recieve any e-mails from the camp.

Signature*

Summer Camp Registration-Mini Camp

Camper's Information

Cabin Buddy

Parent or Legal Guardian Information

Church Information

Email Confirmation

Other Information

Health Information

Payment Information

Camper Release