Jr. Camp 2026 Student Registration Form
Jr. Camp is July 20, 21, 22 (Monday-Wednesday). Grade assignment is base on the grade completed THIS (2025-26) school year. 150 children will be registered (30 per grade.) PLEASE NOTE: If a grade shows as full below, please submit your child to the waiting list. We will allow 15 children on the waiting list.
Grade Child Completed this School Year:
*
Grade:
1st
2nd
3rd
4th
5th
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Student Information
Page 1 of 3
Child's Preferred Name:
*
Last Name:
*
Age
*
T-Shirt Size:
*
Please Select
YS
YM
YL
AS
AM
AL
AXL
A2X
A3X
Emergency Contact Name:
*
Emergency Contact Phone:
*
Format: (000) 000-0000.
Who is allowed to pick up your child?
*
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Parent(s) Information
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Parent's Email
*
example@example.com
Mother's Name
*
Preferred Name
Last Name
Mother's Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Father's Name
Preferred Name
Last Name
Father's Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred number for text communications:
*
Mother
Father
Other
If Other, enter the preferred number:
Please enter a valid phone number.
Format: (000) 000-0000.
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Medical History & Medication Information
Page 3 of 3
CURRENT Chronic Medical Problems:
For example: Diabetes, Cancer, Seizures, Etc.
Any impairments? (Other than glasses)
For example: Hearing, Broken Bones, etc.?
Allergies? (Other than seasonal)
For example: Bee stings, medications, food, etc. Please provide EpiPens as needed.
Daily medication(s) your child takes:
For example: XYZ Medication - Dosage amount
Taking meds during camp?
*
Please Select
Yes
No
If 'No" is selected, please ignore the Medication Administration needs below.
Medication Administration needs:
NOTE: This ONLY needs to be answered if your child will be taking prescribed medication during camp.
Can your child swim?
*
Please Select
Yes
No
If 'NO', please provide arm floats or life vest. If your child cannot safely swim in ALL areas of a pool unassisted, please answer 'NO'.
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Just a couple more questions...
This information is ONLY for analytical reporting purposes inside of Peace Haven Baptist Church to understand the demographics of Jr. Camp. We GUARANTEE this will not be shared with any other organizations or entities.
Where did your child attend school this year?
*
City in which your family resides?
*
Parent's Signature
*
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