2023 Youth Power Up Camp Registration Form

1
Child's Name* This field is required.
2
Gender* This field is required.
Male
Female
3
Birth Date* This field is required.
Month
Day
Year
4
Grade entering in the fall
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
5
Address
Street
City
State/ZIP
6
Home Phone* This field is required.
Area Code
Phone Number
7
Parent/Legal Guardian* This field is required.
8
Relation* This field is required.
9
Work Phone* This field is required.
Area Code
Phone Number
10
Cell Phone
Area Code
Phone Number
11
Parent /Legal Guardian 2
12
Relation 2
13
Work Phone 2
Area Code
Phone Number
14
Cell Phone 2
Area Code
Phone Number
15
Parent's/Guardian's Email
16
Emergency Contact Name(if parent or guardian is not avaliable)* This field is required.
17
Emergency Number* This field is required.
Area Code
Phone Number
18
Is child free from infectious diseases or conditions?* This field is required.
Yes
No
19
Are immunications up to date?* This field is required.
Yes
No
20
All fileds are required below. If nothing applies, please put "NONE" in the box. Thanks.
21
Any activity the child should be restricted from?* This field is required.
22
Any physical, mental or other condition that would require special attention or medication while at Power Up Week?* This field is required.
23
List any allergies (ex: bees,peanuts, dairy)* This field is required.
24
Any dietary needs that we should know about?* This field is required.
25
Camper Release (List anyone, including parents, to whom your camper can be released)* This field is required.
26
Be certain to enter your email address correctly on the registration form to receive confirmation via email with in 2 weeks
27
By hitting submit and putting your initials, you agree that you are the parent or legal guardian of the above-named child, and are over the age of 18. In case of a medical emergency or general medical care, I give consent for medical treatment for the above-named child by authorized personnel. I understand that the above-named child will only be released to the names listed above, an update may be done after registration. I certify that my child has my permission to attend the Peaceful Rest Youth Power Up Camp and participate in all activities. I authorize Peaceful Rest Missionary Baptist Church to use my camper's picture, testimony, and video in any promotional materials (web, print, or media).
28
Electronic signature, please initial* This field is required.
Should be Empty: