Summer Camp Registration Form

Youth Training Camp Registration
Participant Information
Participant's Name*

First NameLast Name
Preferred Name (Nickname)
Birth Date*

MonthDayYear
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant's Cell Number*
Participant's E-mail*
example@example.com
Church information

Church you AttendHow long have you attended?
Are you active in your church? If so, explain and share you activities.
Have you accepted Jesus as your Lord and Savior? If so please share you testimony. Explain the scriptural basis for your salvation, when and where you were saved.*
Personal References (Required) All references will be contact by email.
Pastor Reference*

Full NameEmail Address
Ministry Leader Reference*

Full NameEmail Address
Teacher or Mentor Reference*

Full NameEmail Address
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Cell Number*
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship
Phone Number*
Alt. Phone Number
Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.*
I give permission for my voice and/or image to be used for promotional and publicity purposes.*
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature

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Should be Empty:

Youth Training Camp Registration

Participant Information