Impact Camp Registration Form

Camp Registration Form

These forms are required for your children to attend camp.
Camper's Information
Member ID
Camper Name*
Nickname
Date of Birth*

YearMonthDay
Age*
NOTE: Campers must be between the ages of 8 and 13 to attend. This camp is designed exclusively for boys.
School Camper Attends
Camp Registering For?*
T-Shirt Size

Emergency Contacts/Authorized Pickup

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Emergency Contact #1
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Format: (000) 000-0000.
Secondary Phone Number*
Format: (000) 000-0000.
Relationship to Child*
Emergency Contact #2
Full Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Format: (000) 000-0000.
Secondary Phone Number*
Format: (000) 000-0000.
Relationship to Child*

Meck Investment Company has permission to secure emergency transportation for my child in the event of an illness or injury which requires emergency treatment. The emergency transportation service will determine the facility to which my child will be transported.*
Type first and last name above to consent
Sign Document*
Date Signed*

MonthDayYear
Camp Director Name and Contact Info
Should be Empty:

Camp Registration Form