Camper Registration

Published by gospelchapel on

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SRBC Registration
Camp is open to boys and girls, ages 6 - 14

One application PER CHILD (you cannot list multiple children on one application).

For Registration Questions: (573) 318-4104 or michelsennathan@gmail.com
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* Indicates required question
July 24-28 | 9:00AM - 4:00PM
Camper's First Name *
Your answer
Camper's Last Name *
Your answer
Camper's Mailing Address *
Your answer
Camper's Age *
During week of camp
Your answer
Camper's Gender
Clear selection
Parent or Guardian's Full Name
Must be over 18
Your answer
Daytime Phone Number *
Work or Home
Your answer
Mobile Phone Number
List Cell if different than Daytime
Your answer
Email Address *
Staff will use email to contact you
Your answer
Emergency Contact Person *
Please list relationship after name (e.g. Jane Doe, Neighbor)
Your answer
Emergency Contact Phone Number *
Phone number for person above
Your answer
Medical Insurance Company (If applicable)
List full company name
Your answer
Medical Insurance Policy Number (If applicable)
Policy number here
Your answer
Date of Last Tetanus Shot
Or best estimate
Your answer
Any Allergies (food or other)
Please indicate clearly if camper has any allergy or any special meal requirements.
Your answer
Any conditions or concerns? Special requests, specific requirements?
e.g.: Daily Medications, Asthma, Drug Sensitivities, Diabetes, Seizures, Other?
Your answer
Will your child be riding the bus? *
Please note pick-up, drop-off or both.
Your answer
How did you hear about our camp?
Your answer
Submit
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