CVC Junkyard Redemption Summer Camp Registration Form

CVC - Summer Day Camp Registration Form

Junkyard Redemption | June 23-26, 2026 | 9 a.m. - 12 p.m. | Children 5-12
A separate registration form is required for each child.
Child's Name

First NameLast Name
Child's Age
Age
Birthdate

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Parent/Guardian Alt Name

First NameLast Name
Parent/Guardian Alt Number
Format: (000) 000-0000.
Emergency Contact

First NameLast NameRelationship to Child
Emergency Contact Phone Number
Format: (000) 000-0000.
Emergency Contact Alt Number
Format: (000) 000-0000.
Food Allergies?
If yes to food allergies, please list
Medical Concerns?
If yes to medical concerns, please list
Family Doctor

First NameLast Name
Family Doctor Phone
Please enter a valid phone number.Format: (000) 000-0000.
Special Needs?
If yes to special needs, please list

Sibling(s) Attending

Person(s) Who May Pick up this Child

Will Transportation be Needed? Transportation will be limited to Perkins City Limits Only.
If your child will be riding the bus home after SDC, a parent or authorized guardian must be present at the drop-off location. Children will not be released from the bus without a parent/guardian present.
May we have permission to use the child's photograph in church publications?
Do you attend church in the Perkins area?
Signature
Printed Name

First NameLast Name
A separate registration form is required for each child.
Should be Empty:

CVC - Summer Day Camp Registration Form