Camp Penuel East Camper Registration

CAMPER REGISTRATION FORM
Which week?*
All information must be given by a parent or guardian.

This form must be filled out completely.
Camper Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Age*
(All Campers Must be between 7 - 11 years old NO EXCEPTIONS)
Gender*
Grade Entering
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent or Guardian 1*

First NameLast Name
Relationship*
Email
example@example.com
Cell Phone*
Format: (000) 000-0000.
Other Phone
Format: (000) 000-0000.
Parent or Guardian 2

First NameLast Name
Relationship
Cell Phone
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone
Format: (000) 000-0000.
Person Other Than Parent(s) to Contact in Case of Emergency
Emergency Contact Name*
Relationship
Cell Phone*
Format: (000) 000-0000.
Other Phone
Format: (000) 000-0000.
YesNo
Church Name
(If not, we'll connect you with a local church after camp is over!)
YesNo
TO BE READ AND SIGNED BY CAMPER:

I agree to follow the rules at Camp Penuel East and obey the staff members and counselors while at camp and do my best to get along with other campers.
Camper's Signature

Clear
Date

MonthDayYear
Date