MS Camp Registration

1. Name *

2. Address, City, ST/ZIP *

3. Grade (completed 5th & up to 8th grade) *

4. School *

5. Gender * Female Male

6. Birthday (must be 11 yrs old by August 1) *

7. Food Restrictions or Allergies *

8. Student's Email *

9. Student's Phone *

10. Emergency Contact Person / Parent *

11. Phone # Emergency Contact Person *

12. Parent's Email *

13. Parent's Phone *

14. Please check box if a parent of the student is currently incarcerated to receive information about a potential scholarship. *

• yes
• no

15. Check All That Apply --then click (Submit to Pay) *

• Yes, I understand this is a non-refundable but transferable deposit
• Reserve my spot $50 -by April 5th
• I am paying in full to get the Early-Bird Discount for Camp of $225 -by May 10th
• I am paying by cash or check (give it to your Campus Life/City Life Leader).