Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

Dietary Requirements

(If other, let us know in the medical requirements field above)

Gluten Free

Dairy Free

Vegetarian

Vegan

Other

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

2nd Emergency Contact Name *

First Name

Last Name

2nd Emergency Contact Phone *

(###)

###

####

Camper(s) agree to abide by all the camp rules and safety measures. I understand that if I cancel after Jan 1 2025 I will only receive a 50% refund. I permit my child to receive pain medication and seek medical assistance if leaders see fit. *

Yes, I am permitting my youth to attend camp.