Non-Camper SR

Name *

First

Last

Age during camp *

Date of Birth 00/00/00 *

Gender *

Male Female

Registrant's Email (if applicable) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone Number *

Parent/Guardian Name (if under 21 yrs old) *

Parent/Guardian Phone *

Alt. Phone Number *

Emergency Contact *

Phone Number *

Church location (city, state) *

Church Name *

Your Pastor's Name *

Have you received the gift of the Holy Ghost? *

yes no

Have you been baptized in Jesus' Name? *

yes no

Have you been convicted of any crimes involving inappropriate behavior with children? *

Yes No

If yes, please explain: *

List any known medical conditions the camp should be aware of: *

List any medications that may be taken during camp: *

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