2017 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 2017 Urshlem 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 2017 Urshlem 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 MGOCSM and DSWA 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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