Events

 

Startown Kids Summer Camp!

When: August 6-10, 2012

Ages: Completed 1st - 5th Graders
Location: Ridgecrest, North Carolina

Space is limited. Deposit and Registration are required to reserve your spot on the camp roster on 'First Come - First Serve' basis. Balance needs to be paid by July 15, 2012.

NOTE: By submitting this registration form for your child to attend Startown Kids Summer Camp, you understand and agree that Bethlehem Church, including staff, are not liable for any injuries incurred during or as a result of your child participating in camp.

* marks required fields
 
*Your Name:
*Your E-mail Address:
Phone Number: 
   
   
Address:
City/State/ZipCode:
Phone #:
Cell Phone #:
Email:
Video & Still-Shot Photography will be recorded at camp. Do you give permission for Bethlehem Church to use video shots or photographs of your child in future publicity and end-of-camp wrap-up video?:
Yes No
:
Chaperone/Counselor T-Shirt Size:
YS YM YL AS AM AL XL 2X
Child Information
Name:
Gender:
Date of Birth:
Special Health / Allergy / Other Concerns:
Emergency Contact Name:
Emergency Contact Number:
Emergency Contact Relation:
Child's Address:
Child's City/State/ZipCode:
Child's Home Phone:
Child's Completed Grade:
Chaperone/Counselor Relationship to Jesus Christ:
Child's T-Shirt Size:
YS YM YL AS AM AL XL 2X
Parent/Guardian:
Relationship:
Phone 1:
Phone 2:
Mobile Phone:
Email:
Other Emergency Contact Person:
Phone:
Family Physician:
Phone:
Insurance Company:
Policy #:
Allergies::
Previous Serious Illness/Concerns (seizures, dizziness,etc.)::
Current Medications:
I hereby authorize Bethlehem Children's Ministry to take my child for medical treatment in the event of an emergency in which neither parent nor legal guardian can be reached.:
Yes No
Signature:
Date:
 
  Quantity
Total Cost: : $225.00
   
   
 
  Quantity
Deposit with Registration: : $50.00