LCC 2023 Registration Form

Lost Coast Camp 2023 Registration Form

Camp is ON, and registration is open for return campers now, and for new campers on March 1. Take a look at the website www.lostcoastcamp.org and see pictures of the new lodge here at 7B Ranch.
Registration Fees will be paid through PayPal and must be completed in order to complete the registration process online. YOU DO NOT need to have a PayPal account to use this system and may use a credit card or debit card. If you do not have a Paypal account you may sign in as a "guest".

REGISTER HERE AND THEN YOU CAN REQUEST A CAMPERSHIP

Only one camper may be registered at a time.
Camper Information

Please fill out information about your camper. If you have more than one camper to register for camp, please fill out a separate forms for each camper.
Camper Name*

First NameMiddle NameLast NameSuffix
Nickname or preferred name
Session camper is registering for*
Camper address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Camper mailing address if different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Camper email (if applicable)
example@example.com
Camper Birthday*

MonthDayYear
Date
Age while at camp 2023*
Grade entering fall 2023*
Camper T-shirt size*

Child SmallChild MediumChild LargeAdult SmallAdult MediumAdult LargeAdult X-Large
Camper Gender*

FemaleMale
School camper attended 2022-2023*
School camper will attended 2023-2024*
TRANSPORTATION: How will your child arrive and depart from Camp? (We cannot provide van service for all) *
Parent/Guardian Information
Parent/guardian 1 full name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing address if different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email where you would like to receive confirmation and information*
example@example.com
Cell number*

Area CodePhone Number
Home number

Area CodePhone Number
Parent/guardian 2 full name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mailing address if different

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell number

Area CodePhone Number
Home number

Area CodePhone Number
Emergency Contacts

Please provide two extra emergency contacts
Emergency contact 1*

First NameLast Name
Emergency contact relationship to camper*
Daytime phone number*

Area CodePhone Number
Evening phone number if different

Area CodePhone Number
Emergency contact 2*

First NameLast Name
Emergency contact relationship to camper*
Daytime phone number*

Area CodePhone Number
Evening phone number if different

Area CodePhone Number
Who should we contact first with information regarding camper?*
Ex: Parent 1, parent 2, emergency contact 1, emergency contact 2.

Submission Form
What's your connection to Camp? How did you hear about us?*
Is a campership requested?*

YesNo
If requested, fill out the LCC 2023 Campership form HERE:

https://www.jotform.com/build/202425925157051
CAMPERSHIPS

When approved, the campership will be directly applied to your existing registration. We never turn away a camper for lack of money but ask all to contribute the maximum amount possible with payment plans etc. Call 707 629 3547 or 629 3656 to discuss
CANCELLATION POLICY

There is a $50 cancellation fee and, if the camper's spot is not filled, only 50% of the amount paid will be returned
Contact us ASAP!
WAIVER AND RELEASE OF ALL CLAIMS, CONSENT TO TREAT, AND PHOTO RELEASE:

I, as the parent or legal guardian of the registered who is currently under the age of 18, grant permission for the registered camper to attend Lost Coast Camp and do hereby release Lost Coast Camp from any and all liability or responsibility due to any injury that he/she/they may incur as the result of, or arising in any way from participation in activities at or under the direction of Lost Coast Camp. I am fully aware and consent to accept these risks and voluntarily agree to allow his/her/their participation in activities. I give Lost Coast Camp permission to provide routine healthcare services and administer medications provided for my camper. If I cannot be consulted in an emergency, I hereby give permission to the physician selected by a representative of Lost Coast Camp to hospitalize, secure treatment for, and to order injections, anesthesia, and/or surgery for the person named above. I will take primary responsibility for any fees or charges at any clinic, facility, or hospital arising from the treatment of injury or illness.

I furthermore understand Lost Coast Camp 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 Lost Coast Camp will not identify 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
Signature

Clear
Relationship to registered camper:*
Today's date*

MonthDayYear
Date
Please verify that you are human*
REGISTRATION FEE $25 (non-refundable)
Registration Fee*

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Upon completion of filling in all areas of form, click "Submit Form". You will then be taken to PayPal where you will pay and the 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. Do you have questions or need help with online registration? Contact us!
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Lost Coast Camp 2023 Registration Form

Camper Information

Parent/Guardian Information

Emergency Contacts

Camper Health Form

Submission Form