Ebenezer Lutheran Church - Disciple Camp Registration 2017
Complete one for EACH camper!
Camp Dates: July 23-27, 2017
Day Campers: $170 ($200 after June 11)
Overnight Campers: $320 ($350 after June 11)
All registrations due by July 2
Email address *
Camper's Name *
Your answer
Camper's Age *
Your answer
Female/Male *
Phone *
Your answer
Mailing Address *
Your answer
Camper's Grade In the Fall *
T-Shirt Size *
List Any Health Conditions Staff Should Know About
Your answer
Insurance Policy # *
Your answer
Insurance Company Name *
Your answer
Name and Phone # of Child's Physician *
Your answer
Does the camp director or other authorized person have permission to give your camper medical attention should it be needed? *
List the name and phone number of the person we should contact should we need him/her during disciple camp (family and non-family contacts). List all phone number with clear descriptions (i.e., John's cell, Mary's work, grandmother landline, etc.) *
Your answer
Payment to be made (checks should be mailed to Ebenezer Lutheran Church, 1301 Richland Street, Columbia, SC 29201) *
Check Number
Your answer
Credit Card Information (name on card, card number, expiration date, security code on back, billing zip code)
Your answer
Publication/Web Picture Permission - I grant permission for Ebenezer Lutheran Church to publish photos of my camper on the church's website or Facebook page. I give Ebenezer Lutheran Church the perpetual, royalty-free right to use my child's photo in any manner including in publications and websites. I understand that both the various publications and Websites have a large audience and my camper's photos will be available to the general public. I further understand that Ebenezer Lutheran Church assumes no liability or responsibility whatsoever concerning any consequences of such use. I further state that I have the right to give this permission as I am the camper's parent or legal guardian. I understand that if I give notice to any Ebenezer staff member or to the webmaster that I object to any particular picture on the website, it will be removed as soon as possible. *
If web photo permission is yes, include First Name on photos?
Signature of parent/guardian. By typing your FULL NAME you certify that this form is accurate to the best of your knowledge. *
Your answer
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Additional Terms