Church Name: 

________________________________________________________________________________
 Child's Information

             Child's Name: 
               Address: 
                      City:     State     Zip 
                  Phone: 
                     Age:          Birth Date: 
Grade Completed:    Male / Female: 
Camp Attending (Primary or Junior)   
I Prefer my child not participate in mountain climbing: 

      Parent or Legal Guardian    Phone: 
             Emergency Contact     Phone: 
Medical Insurance Company 
Policy #:    Plan #:    Group #: 

________________________________________________________________________________
Health History
Allergies:
 
Name and dosage of Medications that must be taken at camp: 
 
Existing Conditions:
                     Heart   
                Diabetes   
Nervous Condition   
              Handicap   
                 Asthma   
                    Colds   
                    Other   

________________________________________________________________________________
Registration Work Sheet

Primary Camp ($80.00) (NEW LOWER COST)        Completed grades 1st – 3rd
Junior Camp ($115.00) (NEW LOWER COST)    Completed grades 4th – 6th
Multiple Child Discount                                            For second & each additional child ($10) each
Additional Children Attending                            

Total Cost of Registration                                         

________________________________________________________________________________