Please fill out this form completely.

Mt. Gilead may not be able to process your registration if information is missing. Once you have submitted the form you will be sent a confirmation email. This will be sent to the email address you provide below. Reservations are based on the order registrations are received.

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Camp Attending
First Name
Last Name
Gender Male Female
Age
Date of Birth
(MM/DD/YYYY)
Grade in Fall 2010
Address
City
State
Zip
Home Phone
(Ex.: 707-823-4508)
Email Address
A confirmation notice will be sent to this email address
Church Camper Attends
(If applicable, otherwise, use "none")
Group-Mate Requests
Campers will be split up into small groups (Limit 2)
Medications/Allergies
Dietary Needs
Date of Last Tetanus Booster
(MM/DD/YYYY)
Family Physician
Physician's Office Phone
(Ex.: 707-823-4508)
Health Insurance Provider
Policy Number
Emergency Contact Name
(Other than a parent)
Emergency Contact Phone
(For name above)
Would you like to pre-order a T-Shirt? $12 Yes No
T-Shirt Size (if ordering a T-Shirt)
Amount to be Charged
$45+$12 if ordering a T-Shirt
Card Type
Credit Card Number
(Ex.: XXXX-XXXX-XXXX-XXXX)
Expires
(MM/YY)
V-Code
Last 3 digits on back of card
Name as it Appears on Card