Registration Form

Attendee Information:

First Name* Middle Initial Last Name* Age*

Gender:* Male Female

Upcoming Grade in 2010* Birth date:* Month Day Year

Father/Legal Guardian's First Name Last Name

Mother/Legal Guardian's First Name Last Name

Address and Contact Information Street Address/Box#* City* State* Zip Code*

Home Phone (including area code)* Emergency Phone (including area code)

Parent's E-Mail Camper's E-mail

Note: By providing your e-mail address, you are granting permission to Camp Witness to send occasional announcements and communications via e-mail. These may be related to the specific camp being registered for or general announcements concerning the camp's activities.

Health Information: Health Problems that Camp should know about

Allergies

Date of Last Tetanus Shot: Month Year

Church Information:

Churches are alphabetical by City

Home Church Sponsoring Church

ONLY ENTER the next three field if you were unable to select a church from the list above

Church Name Church City Pastor's Name

Attendance Information: Which Camp do you wish to attend?*

Have you attended Camp Witness before:* Yes No

Camp T-Shirt Options:

Shirts are sold out for this year.

Extra Information:

I will go home with my parents. Yes No I'm not going home with my parents, I'm going home with

Cabin mate Preferences

Payment Method Please contact the camp director if a camp scholarship is needed.

How did you first hear about this year's camping season?

Any Additional Comments?