Global Kingdom Builders Movement Youth Camp Enrollment Form
Camper's Information
Camper's Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Additional #1 Camper's Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Additional #2 Camper's Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Additional #3 Camper's Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Additional #4 Camper's Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Additional #5 Camper's Name
First Name
Last Name
Age
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male
Female
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School Name
School Name
School Name
School Name
School Name
School/Grade Level
School/Grade Level
School/Grade Level
School/Grade Level
School/Grade Level
School/Grade Level
Camper's Photo (Optional)
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Parent/Guardian Information
The parents/guardian listed below will be the authorized person to pick-up the child after the camp.
The parents/guardian listed below will also be the primary emergency contact person.
Name
First Name
Last Name
Relation
Phone Number
-
Area Code
Phone Number
Picture upload
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Name
First Name
Last Name
Relation
Phone Number
-
Area Code
Phone Number
Picture upload
Browse Files
Cancel
of
Medical Information
Does the child have any allergies? If yes, please list them below with Name.
Does the child have any previous injuries? If yes, please explain them below:
Does the child have any current medical conditions? If yes, please list them below:
Does the child takes any medication? If yes, please list them below and explain its purpose:
Donations
Method of Payment
Please Select
Cash
Check
Credit Card
Bank Transfer
Wire Transfer
PayPal
Donation Amount
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( X )
USD
Description
Payment Methods
Credit Card
Apple Pay
After submitting the form, you will be redirected to Apple Pay to complete the payment.
Google Pay
After submitting the form, you will be redirected to Google Pay to complete the payment.
Cash App Pay
After submitting the form, you will be redirected to Cash App Pay to complete the payment.
ACH Bank Transfer
Authorization
I, the parent/guardian of this camper gives authority to the staff of this camp to apply judgment in regards to medical assistance in the event of an accident, injury, or illness if the emergency contact person cannot be reached. I authorized first aid, medical/surgical diagnosis, and treatment which may deem necessary.
I released the organizers, coaches, staff, or managers of this camp for any responsibility in case of accident, illness, or injury during my child's enrollment.
I confirm that all information given in this form is true, complete, and accurate.
Parent/Guardian Signature
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