Kidz Kamp Registration

Mt. Gilead Kidz Kamp Registration

We are excited to have you join us for Kidz Kamp 2008! Please print and fill out this form completely. When you have it completed, please mail it along with a signed medical release form and your registration fee to insure your camper’s spot at camp.

First Name:		Last Name
Gender:	Age:	Birth Date:	Grade in Fall:
Address:
City:		State:	Zip:
Phone #: ( )		Parents Email:
Church Attending:
Health Care Provider:		Policy #:
Date of last Tetanus:		Dr. Name:
Dr. Office Phone #: ( )		Medications/Allergies:

Emergency Contact Name (other than parent):
Emergency Contact Phone #: ( )
Dietary Concerns:
Pre-Order Camp Shirt	Yes No	Size:
Select Day Attending:	June 30 July 1 July 2 July 3
Payment Type: Credit Card ATM Check (enclosed)
Card Type: Visa Mastercard		Card #:
V-Code:	Exp.:	Amount to charge: $35
Cardholder's Signature: