PLEASE COMPLETE AND GIVE TO YOUR
CHURCH'S REGISTRATION PERSON
Eastern Pennsylvania Christian Service Camp
Registration Card
CIRCLE ONE: Male
Female
Name: ______________________________________________
Address: _____________________________________________
City: ______________________Phone: _____________________
State: _____________________Zip Code: ___________________
E-mail address: ________________________________________
Birthdate: __________________ Grade Completed: __________
CIRCLE THE APPROPRIATE WEEK:
First Chance Camp Junior Week
Middle Week Soccer Week
Junior High Week Senior High
Week High Ropes Course
Note: A non-refundable deposit of $25.00 must accompany
this card for
all weeks except First Chance and should be sent to:
Camp Epachiseca, 23 Zaner's Bridge Rd., Stillwater, PA 17878.
Registrations postmarked by midnight, June 15th are eligible for an
Early Bird Bonus (see camp brochure for details and current camp fees.)
If deposit is received by June 15, our "Early
Bird" deadline, the cost
is $110.00. After June 15, the cost in $150.00. Checks should be made
payable to "E. PA Christian Service Assembly". If your church plans
to pay any or all of the camp fee, please specify the exact
dollar amount the church will pay. YOUR CARD MUST BE SIGNED
BY AN ELDER OR MINISTER.
Our church will pay $_______ Deposit amount enclosed
$________
Name of church: _________________________________________
Balance due on arrival: $_________ Date: __________
Signed: _________________________________________
(minister or elder endorsement for church to pay)
We have read and agree to the camp dress code:
Date: _________
Camper signature: _____________________________________
Parent signature: ______________________________________
HEALTH INFORMATION
I attest that __________________________ is in good
physical condition and
is able to participate in all camp activities.
EXCEPTIONS: ______________________________________________________
If camper has a history of allergies, please list: __________________________
__________________________________________________________________
Date of last tetanus booster: _________________________________________
Health Insurance Co. Name: __________________
Group/Policy No. ___________
Family Physician: ______________________ City: _____________ Phone: ________
I give my permission for the camp to dispense over the counter drugs
in the case of an illness (CIRCLE ONE):
Yes No
Exceptions: __________________________________________________________
IN CASE OF EMERGENCY: I hereby give permission to the physician selected
by the
camp management or dean to secure proper treatment for my child
as named on this card. Doctors' services, treatments, or hospitalizations
which exceed the camp's
insurance coverage are to be charged to our family
insurance or to me personally. If there
is only one legal guardian, write
NONE on the other line. Signatures are required for
child to participate in
camp. They also acknowledge that the parents/guardians have read
and
agree to the RISK OF INJURY & WAIVER OF LIABILITY statements as they
appear
in the Camp Brochure.
Father/Male Guardian Signature: __________________________________________
Date: ____________
Mother/Female Guardian Signature: ________________________________________
Date: ____________
Medications brought to camp (to be filled out by the Camp Nurse): ____________________________________________________________________________________
______________________________________________________________________