You may register online OR you may register by enrollment card in the mail (cards will be mailed out in early June).

If you choose to register online, you may pay online OR at check-in.
Online payment will have a 2.9% surcharge + 30 cents per camper to cover the payment processing fees.

A PARENT or GUARDIAN must fill out this form.

If you have questions about camp, please call David Goin (618.231.2629) or Melissa Goin (618.838.8455).
If you have technical difficulties with this form, please call Stephen Bradd (217.935.5058).



Junior Session (ages 8 - 10):
July 7 - 11 (Sun 3 PM - Thur 7 PM) = $100

Junior High Session (ages 11 - 13):
July 14 - 19 (Sun 3 PM - Fri 7 PM) = $110

Senior High Session (ages 14 - 18):
July 21 - 26 (Sun 3 PM - Fri 7 PM) = $110

Which camp session will your child be attending? *
Camper's Name *
Mailing Address *
City *
State *
Zip Code (5 digits) *
Camper's Gender *
Camper's Birthday *
Camper's Parent(s) or Guardian(s) *
Phone Number for Parent or Guardian (best number to reach you at in case of an emergency) *
Family Doctor *
Family Doctor Phone Number *
Church that the Camper Attends? *
Member of that Church? *
Preacher's Name *
Camper has permission to go BOATING? *
Camper has permission to go SWIMMING? *
When did the camper have his/her last TETANUS shot?
Does the camper have any ALLERGIES? If so, please explain.
Is the camper on any MEDICATION? If so, please explain.
Health insurance company *
Health insurance policy number *
DIGITAL SIGNATURE OF PARENT OR GUARDIAN: Typing out your full legal name below indicates all information submitted in this form is correct AND that in the event that you cannot be reached for consent, you hereby authorize Gela Goin, Melissa Goin, or David Goin (director of the Little Egypt Christian Youth Camp) or the camp nurse to give consent to a physician of their choice to render any necessary emergency medical treatment in case of illness or accident. This is important since hospitals & doctors will not give emergency treatment without consent of a parent or guardian. *
Parent's Email Address *
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