Elevate Summer Camp

Elevate Summer Camp Registration

Shore Fellowship Church
Teenager's Name

First NameLast Name
Parent's Name

First NameLast Name
Parent's Email
Parent's Phone Number

Area CodePhone Number
Grade
Do you have a 2012-13 medical release on file?
Does your student require any daily medical attention such as medication or insulin shots? If so, please explain

Camp - Full Amount$375.00

Camp - Remaining Balance (Only if you paid the deposit before May 26th)$225.00

Camp - Remaining Balance (Only if you paid the deposit after May 26th)$250.00

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Elevate Summer Camp Registration