Jr. High Winter Blast Registration 2018

Sr. High Winter Camp

January 10-12, 2020
Camper Information

Please register each child separately
Full Name *

First Name Last Name
Please Select *

Male Female
Age *
Birth Date

Month Day Year
Current Grade *

Grade 9 Grade 10 Grade 11 Grade 12
First Time Camper?

Yes No

Address *

Mailing Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

Area Code Phone Number
Home Church (if Any)
Cabin Buddy Request
Family / Health Information

Parent / Guardians
Parent / Guardian 1 *

First Name Last Name
Phone Number *

Area Code Phone Number
Parent / Guardian 2

First Name Last Name
Alternate Phone Number

Area Code Phone Number
Other Adult Authorized to Pickup Child (ID Required)

First Name Last Name
Phone Number

Area Code Phone Number
Medical Information
Allergies
Medical condtions/restrictions
Last Tetanus Shot
Insurance
Policy#
Doctor / Pediatrician
Dr Phone Number

Area Code Phone Number
Financial Information

Cost: $115. To pay offline, enter "0".
Registration Deposit

USD Suggested Deposit Amount: $25
E-mail
Medical Release
I give my child permission to participate in the activities of Camas Meadows Bible Camp. *
I give consent to any emergency medical treatment deemed necessary by the Camas Meadows Staff for my Child (parents will be notified as soon as possible). *
I absolve Camas Meadows Bible Camp and its personnel of liability for any accident or illness caused by my child's participation in the camp program. *
The parent / guardian submitting this registration are those having legal custody over the child. *
I am not aware of any physical or other limitations that would hinder my child from participating in the camp program. *
I DO NOT grant permission to use pictures or video of my child for camp promotional purposes.

Do not use pictures or video
Parent Signature (Enter Name Here) *
Enter the message as it's shown *
Should be Empty:

Sr. High Winter Camp

Camper Information

Family / Health Information

Medical Information

Financial Information

Medical Release