PLEASE COMPLETE AND GIVE TO YOUR
CHURCH'S REGISTRATION PERSON
Registration Card
CIRCLE ONE:
Male Female
Name: ______________________________________________
Address:
E-mail address: ________________________________________
Birthdate: __________________ Grade Completed:
__________
Cell/Work Phone: ____________________
E-mail: _____________________________
CIRCLE THE APPROPRIATE WEEK:
First Chance Camp Junior Week
Middle School Week
High
School Week
Note: A non-refundable deposit of $25.00
must accompany this card for
all weeks except First Chance and should be sent to:
Registrations postmarked by
Early Bird Bonus (see camp brochure for details and current camp fees.)
If deposit is received by June 15, our "Early Bird" deadline, the
cost
is $175.00. After June 15, the cost in $200.00. Checks
should be made
payable to "E. PA Christian Service Assembly". If your church
plans
to pay any or all of the camp fee, please specify the
exact
dollar amount the church will pay. YOUR CARD MUST BE SIGNED
BY AN ELDER OR MINISTER.
Our church will pay $
Deposit amount enclosed $
Name of church:
Balance due on arrival: $ Date:
Signed: _________________________________________
(minister or elder endorsement for church to pay)
We have read and agree to the camp dress code:
Yes No
Date: ________
Camper signature: _____________________________________
Parent signature: ______________________________________
HEALTH INFORMATION
I attest that __________________________
is in good physical condition and
is able to participate in all camp activities.
EXCEPTIONS: ______________________________________________________
If camper has a history of allergies, please list: __________________________
__________________________________________________________________
Date of last tetanus booster: _________________________________________
Health Insurance
Group/Policy No. ___________
Family Physician: ______________________ City: _____________ Phone: ________
I give my permission for the camp to dispense over the counter drugs
in the case of an illness (CIRCLE ONE):
Yes No
Exceptions: __________________________________________________________
IN CASE OF EMERGENCY: I hereby give permission to the physician selected
by the camp management or dean to secure proper treatment for my child
as named on this card. Doctors' services, treatments, or hospitalizations
which exceed the camp's insurance coverage are to be charged to our
family
insurance or to me personally. If there is only one legal guardian, write
NONE on the other line. Signatures are required for child to participate
in
camp. They also acknowledge that the parents/guardians have read and
agree to the RISK OF INJURY & WAIVER OF LIABILITY statements as they
appear in the
Father/Male Guardian Signature: __________________________________________
Date: ____________
Mother/Female Guardian Signature: ________________________________________
Date: ____________
Medications brought to camp (to be filled out by the
______________________________________________________________________