Camper's Application
The total cost of MDSC is $275.00 per camper.
The first $100.00 must be received for your child's application to be held.
This is a non-refundable deposit.
A $25.00 Early Registration Discount is for any application and deposit received by April 1.

Payments can be submitted via Paypal or mailed to:
Mason Dixon Scholarship Camp
c/o Anne Barrows
8995 Water St Rd
Walkersville, MD 21793

The Camper's book does not need to be finished to Register for Camp.
It will need to be finished before camp.

Applicant's First Name
Your answer
Applicant's Last Name
Your answer
Week Of Camp
Applicant's Date of Birth
MM
/
DD
/
YYYY
Grade for Fall of 2017
AWANA Church
Seniors - Did you earn a Citation Award?
Applicant's Address
Your answer
City
Your answer
State
Zip Code
Your answer
Gender
Home Phone
Your answer
Family Email
Your answer
First time Camper at MDSC
T-shirt Size
Verse Card Translation
Roommate Request
Your answer
Book Completed in 2016 - 2017
Journey Kids- if doing old curriculum ~ check 2 boxes (Main Study and Elective)
Required
Medical Insurance Company
Your answer
Policy Number
Your answer
Group Number
Your answer
Policyholder's Name
Your answer
Policyholder's Birthday
MM
/
DD
/
YYYY
Will the Camper be over 18 yrs old at camp?
Physicians Name
Your answer
Physicians' Phone Number
Your answer
Date of Last Physical
MM
/
DD
/
YYYY
Date of Most Recent Tetanus - This is Required
MM
/
DD
/
YYYY
Food Allergies - This goes to the Kitchen and Nurse
Your answer
The camp nurse has my permission to provide over the counter meds.
Other Medical Allergies or Emotional Issues - This ONLY goes to the Nurse
Your answer
Medications Camper will be taking while at camp - this includes vitamins.
Please List all and dosage
Your answer
Does the Camper have any physical limitations that would restrict any camp activities?
Parent's Names
Your answer
Phone Numbers to Contact Parents (ie - Cell, Work, Home)
Your answer
Emergency Contact if we are unable to contact Parents
Your answer
By typing your name below this acts as your legal signature.
Your answer
Parental Consent and Release of Liability
Required
Payment Options
Submit
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