Disciple Camp Registration Form
Camp Kinard
July 21-25, 2019

One registration form needed PER CAMPER.

Camper's Name *
Your answer
Camper's Age *
Your answer
Gender *
Grade Completed in July 2019 *
Your answer
T-shirt Size *
Please list any health conditions the staff should know about:
Your answer
Parent(s) names *
Your answer
Street address *
Your answer
City, State ZIP *
Your answer
Best phone number to reach you *
Your answer
Email *
Your answer
Insurance Policy Name and # *
Your answer
Name and Phone # of Child's Physician *
Your answer
Does the camp director or other authorized person have your permission to have your child given medical attention should it be needed? *
List the name and phone number of the person we should contact should we need him or her during Disciple Camp (family and non-family contacts). *
Please list all phone numbers with clear descriptions (Ex. "John's cell," "Mary's work," "grandmother's landline.")
Your answer
Home church (if not Ebenezer)
Your answer
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