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First Name* Middle Initial Last Name*

Age* Under 18 will need release and be accompanied by an adult.

Under 18, complete this section: Father/Male Legal Guardian's First Name Last Name

Mother/Female Legal Guardian's First Name Last Name

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

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

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

Enter fields below if Church is not in list above

Church Name Church City Pastor's Name

Attendance Information Which Camp do you wish to attend?*

Have you participated in Camp Witness activities before:* Yes No

Extra Information: Any Additional Comments? If you will only be available certain days, please note that in the comments.