Child's Last Name

Child's First Name

Home Address

City

Zip Code

Parent's Last Name (if different)

Parent's First Name

Home Phone

Work Phone

Childs Date of Birth

Grade Completed

Does child attend Sunday School?

If "Yes", Where?

Medical or other information we need to know.
Please include any food or other allergies.
(Note - If your child has a food allergy
or severe condition then you must
provide any alternative snack for them)

In the event of an emergency and noone answers at home or work,
whom do we call first? Please include a name and phone number.

In the event of an emergency, whom do we call next?

Who may pick up this child at the end of each camp?

May we have permission to photograph your child?

May we have your permission to use your
childs photograph in church publications
for the purpose of promotion?

T-Shirt Size:

Adult size Youth size