MCYA Youth Camp 2019 - Registration Form

MCYA Youth Camp 2019 - Registration Form

July 9th - 13th, 2019
Mt. Hope Bible Camp

9721 Mt Hope Rd, Forbestown, CA 95941
Camper Registration Fee:

*Checks must be postmarked by:

Deadline: June 10th: $250

After June 11th: $280

NOTE: If circumstances should prevent attendance at camp, camper may write a letter of explanation to MCYA Camp Director. If Director determines absence was for a justifiable reason, 50% of your fee may be refundable.
Registering As*
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
Email
example@example.com
Age*
Gender*

MaleFemale
T-shirt Size*
*Camp t-shirts will be included
School Grade Starting in Fall 2019*
*Staff may choose other
Bunking Buddy*
*List name here. Both must submit forms by 1st deadline. 6th graders or 1st time campers only. No guarantees for walk-ins.
Church Name and City:
Health Questionnaire
List of Health Problems (i.e. Asthma, Seizures, etc.) *
*Please type N/A if not applicable
Medications Currently Taking*
*Please type N/A if not applicable
Drug Allergies
Date of Last Tetanus Shot*

MonthDayYear
Health Insurance Carrier*
Policy Number*
Parent/Guardian Name*
Parent Phone Number*

Area CodePhone Number
Emergency Contact*
Emergency Phone Number*

Area CodePhone Number
Release of Liability Statement

I, the camper, have read and agree to abide by the rules set by Mt. Hope Bible Conference Center and MCYA. I will accept appropriate disciplinary actions by the camp committee should I violate any camp rules. I agree to release Mt. Hope Bible Conference Center, MCYA, and Camp Staff of any liabilities in the event of an accident during camp.
Camper Signature*

Clear
Please use your mouse to draw your signature.
Parent Permission: (Required for all campers under 18 years of age)

I, the parent/legal guardian, permit my child to participate in MCYA's Summer Camp and release Mt. Hope Bible Conference Center, MCYA and Camp Staff of any liabilities in the event of an accident during camp.
Parent/Legal Guardian Signature*

Clear
Please use your mouse to draw your signature.
After completing this form, please send check/money order made payable
to "MCYA" to this address (DO NOT SEND CASH):

7079 Wilshire Cir.
Sacramento, CA 95822

You can also make a payment using Venmo - our account email is:

MCYA777@gmail.com

If you have questions, please contact us at: contact@mcya.org

Thank you!
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MCYA Youth Camp 2019 - Registration Form

Mt. Hope Bible Camp

Health Questionnaire