Breakout Fusion 2021

Breakout Fusion Registration Form

Please fill out the form carefully for an incredible camp experience!
Student's Name *

First Name Middle Name Last Name
Parent's Name *

First Name Middle Name Last Name
Birth Date *

Month Day Year
Gender *
Grade *
Address *

Street Address

City State / Province

Postal / Zip Code
E-mail
example@example.com
Student's Number
Parents Number *
Parent's Work Number
Church Home (or friend's Church Home)
Shirt Size *
Monday and Tuesday Track Activities (Please select your top 3 choices- some will have limited capacity)

Rock Wall Axe Throwing Pura Vida Bracelet Making Glow in the Dark Dodge Ball Obstacle Course Zorb Ball Painting
Wednesday and Thursday Track Activities (Please select your top 3 choices- some will have limited capacity)

Paintball Canoe, Kayak and Paddle Boarding Pura Vida Bracelet Making Axe Throwing Zorb Ball Painting Rock Wall
Additional Comments or Allergy Info
Please select which days you'll be attending or come all 4 days for a discounted rate! *

Monday $30. (Location: Crossroads Church) Tuesday $30. (Location: Crossroads Church) Wednesday $30. (Location: First Baptist Church) Thursday $30. (Location: First Baptist Church) All 4 Days $100. Select this option if paying cash or check in person. Please select the day(s) above (Also, be sure the boxes under Payment are unchecked in order to submit registration) Volunteer Adult Leader

Payment

All Days Come all days and save $20

$ 100.00

Single Day Select how many days you will attend

$ 30.00 Quantity

Total

$ 0.00

Breakout Fusion Waiver (please download form, complete and email to breakoutfusion@gmail.com)
OTC Med Form (please download form, complete and email to breakoutfusion@gmail.com)
Should be Empty:

Breakout Fusion Registration Form