Thank you for your interest in our youth camp. To register online, please fill out the form below. Please note that ALL information is required. Again, if you have any questions, you may call the youth office @ 330-5724 ext. 4.

(Bolded fields are required.)

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone:

E-Mail:

Confirm E-Mail:

Gender:

Male Female

Roommate Request:

T-Shirt Size:

XXL XL L M S XS

Grade in the fall:

School:

Please supply ALL of the following information.

Medical Insurance Company:

Group Number:

Policy Number:

Insured Policy Holder’s Name (Adult):

Insured Policy Holder’s Birthdate (Adult):

Format: mm/dd/yyyy (i.e. 10/20/1970)

Company Address:

Company Phone:

City:

State:

Zip Code:

List all medication you take on a regular basis and/or any you will bring with you to camp (Prescription medications MUST have pharmacy label and name of doctor):

Date of last Tetanus Shot:

Format: mm/dd/yyyy (i.e. 10/20/1970)

Camper has permission to engage in all camp activities except (list all prohibited activities):

I understand that all due precaution will be taken, but in spite of this, accidents can happen and illness may develop. Therefore, I will not hold the chaperones, Trinity Church or its staff liable for any illness or accident resulting from the above student’s camp experience. In the event I cannot be reached in an emergency, I hereby give permission for the physician selected by the chaperones to hospitalize, secure proper treatment for, and to order injection, anesthesia, x-ray or surgery for my child named above.

FINAL STEPS:
1. Turn in a copy of insurance card
2. Turn in $50 non-refundable deposit
3. Parent come in to sign registration form

| | | | | |