Camper Registration
Child's Name*
Date*
Parent's name(s)*
Parent's Phone*
Parent's Email
Child's Gender*
Last Grade Completed*
Birthdate*
Address*
City*
State*
Zip Code*
Requested Cabin Mate (Not Guaranteed)
T-Shirt Size*






Classes Child is interested in*









Medical Release
Health Insurance Carrier*
Health Insurance Number*
Date*
Note to Parents: Signature of parent or guardian below authorizes Central Church Staff/Camp Advisors to see that the applicant is taken to a doctor or hospital for emergency treatment in the event of an accident, or injury while attending camp. It is also agreed, that Central Church Staff/Camp Advisors, its directors, trustees, officers, or attendants will not be held legally responsible for such accident or injury.
Signature of Parent/Guardian*
Emergency Contact Name*
Phone #*
Allergies
Any other medical conditions we should know about?
ANY ADULT PLANNING TO STAY AT CAMP FOR ANY LENGTH OF TIME must have prior approval from our camp director, Brian Beck. All adult workers must complete a background check and pay $40 for the week to help cover food costs.