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 #: ______________________________
Medical History
Please list significant medical history or chronic conditions:
___________________________________________________
___________________________________________________
___________________________________________________
Allergies: food, medications, insects: _____________________
____________________________________________________
____________________________________________________
Allergy treatments: ____________________________________
____________________________________________________
**Medications that will be brought to camp:
____________________________________________________
____________________________________________________
** All medications MUST be given to the nurse at registration without exception. This includes over the counter drugs as well as prescription medication.
Camp Fees
Registration Fee $240.00 (Before July 1)
$250.00 (After July 1)
Less Deposit (Minimum $100.00) -$________
Final Payment Amount $________
Payment in FULL due by July 15th, 2011
SEND REGISTRATIONS TO:
Tri-Pres Camp
C/O Ashleigh Jones
225 Orono Place, Somerdale, NJ 08083
*Make checks payable to: TRI-PRES CAMP