Parents' Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Daytime Phone *

(###)

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Child's Name *

First Name

Last Name

T-Shirt Size

Youth S

Youth M

Youth L

Youth XL

Emergency Contact 1: Name *

First Name

Last Name

Emergency Contact 1: Phone Number

(###)

###

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Emergency Contact 2: Name *

First Name

Last Name

Emergency Contact 2: Phone Number *

(###)

###

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Primary Physician Name *

In the event of an emergency where medical treatment is required, and I or named contacts are unable to be reached by phone, I authorize the church staff sponsors of this event to obtain the services of a licensed physician. Please attempt to notify me immediately concerning any such emergency.

First Name

Last Name

Primary Physician Phone *

(###)

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I confirm that I am the legal guardian of this child. I give my child permission to attend this camp *

Yes

No

Date Form Submitted *

MM

DD

YYYY