Camp Guadalupe Registration Form

Camp Guadalupe 2019 Camper Registration
Camp Location
*

St. Francis of Assisi, June 24-28 Malvern Retreat House, July 15-19
How did you hear about Camp this year?

Church Bulletin Email Word of mouth Previous camper/volunteer
Family Information
Parent #1 *

First Name Last Name
Cell Number *

Area Code Phone Number
E-mail *
Parent #2

First Name Last Name
Cell Number

Area Code Phone Number

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Emergency Information
Emergency Contact's Name *

First Name Last Name
Relationship *
Phone Number *

Area Code Phone Number
Camper #1
Child #1 *

First Name Last Name
Birth Date *

Month Day Year
Group (age as of 6/1/2019) *

Red 4 yr olds Green 5-6 yr olds Purple 7-8 yr olds Yellow 9-10 yr olds Blue 11-12 yr olds
Please choose T-shirt size for the camper

child small child medium child large adult small adult medium
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the camper prescribed an inhaler or epi-pen? If yes, please explain any instructions.
If you are finished entering all campers, scroll to the bottom of the page.
Camper #2
Child #2

First Name Last Name
Birth Date

Month Day Year
Group (age as of 6/1/2019)

Red 4 yr olds Green 5-6 yr olds Purple 7-8 yr olds Yellow 9-10 yr olds Blue 11-12 yr olds
Please choose T-shirt size for the camper

child small child medium child large adult small adult medium
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the camper prescribed an inhaler or epi-pen? If yes, please explain any instructions.
If you are finished entering all campers, scroll to the bottom of the page.
Camper #3
Child #3

First Name Last Name
Birth Date

Month Day Year
Group (age as of 6/1/2019)

Red 4 yr olds Green 5-6 yr olds Purple 7-8 yr olds Yellow 9-10 yr olds Blue 11-12 yr olds
Please choose T-shirt size for the camper

child small child medium child large adult small adult medium
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the camper prescribed an inhaler or epi-pen? If yes, please explain any instructions.
If you are finished entering all campers, scroll to the bottom of the page.
Camper #4
Child #4

First Name Last Name
Birth Date

Month Day Year
Group (age as of 6/1/2019)

Red 4 yr olds Green 5-6 yr olds Purple 7-8 yr olds Yellow 9-10 yr olds Blue 11-12 yr olds
Please choose T-shirt size for the camper

child small child medium child large adult small adult medium
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the camper prescribed an inhaler or epi-pen? If yes, please explain any instructions.
If you are finished entering all campers, scroll to the bottom of the page.
Camper #5
Child #5

First Name Last Name
Birth Date

Month Day Year
Group (age as of 6/1/2019)

Red 4 yr olds Green 5-6 yr olds Purple 7-8 yr olds Yellow 9-10 yr olds Blue 11-12 yr olds
Please choose T-shirt size for the camper

child small child medium child large adult small adult medium
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.
Is the camper prescribed an inhaler or epi-pen? If yes, please explain any instructions.

Informed Consent and Acknowledgement

BY SIGNING BELOW, I give full permission for my child/children to participate in the Camp Guadalupe activities. The applicant and parent agree that Living Bridges, volunteers, instructors and members of this organization, St.Francis Of Assisi Parish and Malvern Retreat House will not be held responsible for any accidents or losses, however caused, and agree to release all parties involved from claim, lawsuit or damage which may arise as a result of or by reason of such loss or accident. Every precaution will be taken to ensure the safety of the children. I also give permission to have my child/children photographed by the media or camp photographer.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature *
Please type your name to confirm you've read the Consent and Authorization
Registration Payment Due: *

1 Camper $90 2 Campers $165 3 Campers $240 Maximum Family Rate $275
Payment Options *

PayPal (through Living Bridges website) Mail payment
Should be Empty:

Now create your own JotForm - It's free! Create your own JotForm

Camp Guadalupe 2019 Camper Registration

Camper #2

Camper #3

Camper #4

Camper #5