Name           Address

City           State           Zip           Phone

Age (if under 21)            Grade enrolled in NEXT Fall

Registration Fees:  (Choose ONE)                                                               $                                   

 Preschool Registration                                      $20

 Registration                                                      $50

 Early Bird Discount                                          $40

 Morning workshop ONLY                               $30 (CEU credit available)

      Please reserve, optional adult workshop text book $13 [     ]      Participant's book $10 [     ]

 Staff (your position)

Housing Fees Per Week:  (Choose ONE)                                                        $                                   

 Camp owned cabin/dorm                                  $18

 Camper or Trailer hookup                                 $50

Meals:  (Choose ONE)                                                                                                                  $                                                    

 Prepaid (age 10 and under)                               $40

 Prepaid (age 11 and up)                                   $50

 Cafeteria style (pay for what you eat)                $50 (approximately)

                                                                                                                                                            TOTAL DUE     $                                   

Sponsors:  Required for campers under 18 years of age

 I do not have a sponsor and agree to have one appointed

 I do have a sponsor.  Sponsor’s name

(Church groups of 8 or more need to provide a sponsor)

Permission for off site activities:

(Parent or guardian’s signature needed for all off site activities for campers under 18)

Signature:                                                                                                                                                                                                      

Parental Authorization for Emergency Medical Treatment Form:

(ALL campers under 18 MUST bring completed form to camp)

I hereby authorize the physicians in charge of (camper’s name)  to administer any treatment or to administer such anesthetics; and perform such operations as may be deemed necessary or advisable in the diagnosis and treatment of this patient.

Date           Parent/guardian’s signature                                                                            

Camper's name           Age           Last Tetanus Booster

Family Physician           Phone

Witness                                                                                                          Date

Allergies or drug sensitivities

Medications presently being taken

Other information camp nurse should be aware of

Primary Family Insurance           Account Number