Registration Form

Registration Form (Please PRINT this entire form and mail to the address noted at the bottom) 

Name: __________________________________________

Address: ________________________________________             ______________________________________________

Telephone Numbers:      

       Home Phone: _________________________________        

       Work Phone: _________________________________          

       Cell Phone: __________________________________

E-mail: __________________________________________

Sex: ________  Age: ______  Grade Completed: ________

Church: _________________________________________

Bunk Requests:  __________________________________

________________________________________________

**  Please remember to bring appropriate footwear (Something other than just Flip-Flops) to avoid injury.

Medical Release

 In the event I cannot be reached in an emergency, I hereby give permission to the Camp Staff at Tri-Presbytery Junior Camp to hospitalize and secure treatment, for a doctor to order injections, anesthesia or surgery for my child.

 ________________________________________________

Parent’s/Guardian’s Signature

Name of Insured: __________________________________

Insurance Company: _______________________________

Policy #:_________________________________________

Group #:_________________________________________

Authorization’s Phone: ______________________________ 

Emergency Contact Person:

_________________________________________________

Emergency Contact #: ______________________________