2018 Urshlem Men's Summer Camp
Registration
First Name *
Your answer
Middle Initial
Your answer
Last Name *
Your answer
Age *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Grade Level *
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
E-Mail Address *
Your answer
Phone Number *
(ex. 000-000-0000)
Your answer
Special Notes (Food or Allergy Info) *
Your answer
Emergency Contact Name *
First and Last Name
Your answer
Emergency Contact Phone Number *
Number to reach individual in case of an emergency (ex. 000-000-0000)
Your answer
Emergency Contact's Relationship to You *
What is the relationship between the emergency contact and you?
Your answer
Parish Name and Location *
ex: St. Thomas Orthodox Church, Los Angeles, CA
Your answer
Parish Vicar *
Your answer
T-Shirt Size *
Questions or Need More Infomation?
Please reach out to your local Area Council Representative or email: dswamgocsm@gmail.com
Waiver
I as an attendee/participant of the 2018 Urshlem Men's Summer Camp acknowledge and accept the responsibility of safety, liability and medical insurance for myself in case of any emergency and will not hold the Office bearers, Coordinators, or participants of the 2018 Urshlem Men's Summer Camp responsible. In case of an emergency, I give my permission for emergency medical treatment. I take full responsibility to abide by the rules and regulations of the DS-WA MGOCSM and DS-WA Diocesan Center. I, hereby, agree to follow those rules and regulations set by the above-mentioned organizations, and am aware that any failure to do so, may result in my dismissal from the camp site, and if necessary, appropriate legal action may be taken against me. I am aware that it is my responsibility to attend the sessions as scheduled and to maintain the Christian atmosphere of the camp.

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