Middle School Camp Regitration 2012

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IMPACT YOUTH CAMP 2012 REGISTRATION

*Name:
*Home/Main Phone:
*Grade Finished (2011-2012):
*Home Address:
*City:
*State:
*Zip Code:
Date of Birth (MM/DD/YYYY):
*Emergency Contact & Phone Number:
Emergency Contact Relation to Camper:
Check box if you are a guest:
Roommate Preference (List 1 or 2):
*T-Shirt (adult size):
Health Insurance Co:
Health Insurance Policy Holder:
Insurance phone number:
List any allergies or medications:
By checking this box I understand my student & I must sign a Camp Covenant at the parent meeting on :
After submitting this form you will be directed to the PayPal site. If no payment is received this registration will be invalid.

PAY REMAINING BALANCE HERE

PayPal Balance - Tuesday, May 08, 2012

If you need to know your exact balance you can email Katie at Katie@rockwallyouth.org & she can get that to you.

If you need to know your exact balance you can email Katie at Katie@rockwallyouth.org & she can get that to you.

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