Revival Youth Camp Registration
Camp Date: June 16-19, 2021
Please complete one form per student. This form is for our church records. You must ALSO complete the district form at (scroll down and click "Online Registration Here")
Be aware that the district now requires a $20 deposit for each student
For any additional questions please contact us at or text 505-377-7893 (Pastor Ben)
Please save my contact info if you don't already have it
Thank you! We're so excited to bring your students to camp!!
-Pastor Ben & Gabi
Student Name and Age *
Parent/Guardian Name(s) *
Parent/Guardian Preferred Phone Number & Email *
Emergency Contact Name *
List one person we can reach in case you cannot be contacted
Emergency Contact Phone Number *
Student Allergies?
If none, leave blank
Student Medication Requirements?
Please list medication name(s), dosage, and how often it must be taken. If none, leave blank
Any special requirements your student(s) may need?
If none, leave blank
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