Summer 2018 Registration

Summer 2021 - June 14-19

Southland Christian Ministries
Full Name *

First Name Last Name
Camper Sponser
DOB *
E-mail *
Grade In Fall *
Gender *
Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Home Phone *

Area Code Phone Number
Emergency Phone *

Area Code Phone Number
Church Information
Home Church
Church Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Church Phone

Area Code Phone Number
Pastor/Youth Pastor Name
Pastor's Email
Pastor, youth pastor, or church sponsor
Church I'm Coming With *
Camper Agreement
Medical Information
Date of last Tetanus Booster *
Prescribed medications regularly taken
Reason for Taking medication
Specific allergies
Allergic to...

Bee Ant Penicillin
Type of Reaction
Treatment Given
Has your child ever been diagnosed with a medical condition?(e.g. asthma, diabetes, etc.)
If so, Please list here...
Does you child have any history of seizures? *

Yes No
Family Physician *
Physicians Work Phone *

Area Code Phone Number
Specific Activities to be restricted
Reason for Restriction
Food allergy information: Southland Ministries understands the needs of food-allergic campers. The dietician is able to safely and reasonably guide and accommodate campers. Food allergies that are life-threatening will be managed by our kitchen staff. We cannot, however, accommodate for dietary preferences. In these cases, we ask that the parent/guardian send, with the camper, a cooler/container filled with the foods needed for his/her time at camp. We will be happy to allow the sponsor to help your camper with his/her needs in these areas. Thanks you for your cooperation in this matter.
Hospitalization Insurance
Company *
Policy Number *
Parental/Guardian Agreement
PLEASE NOTE: Registration Fee is credited to the full camp payment upon arrival at Southland. Please select only one option below. The registration fee is included in the full price of the camp.

Camp Payment Options

Registration Fee $ 25.00

Pay-in-Full $ 200.00

Project Donation $ 10.00

Enter coupon

Subtotal $ 0.00 Tax $ 0.00 Total $ 0.00

Please contact the camp office at 318.894.9154 to any make registration payments.
Payment Options:

1) Pay only registration fee then pay the Camp fee at registration of the week you have selected

(Registrition fee goes towards the overall price of camp. Registration fee is NOT refundable)

2) Pay the full price online

(This is refundable except for the registration fee that is included in the overall price)
Should be Empty:

Summer 2021 - June 14-19

Church Information

Camper Agreement

Medical Information

Hospitalization Insurance

Parental/Guardian Agreement