Peace Camp Registration

PEACE CAMP 2013 REGISTRATION

PLEASE COMPLETE A SEPARATE FORM FOR EACH CAMPER
(YOU CAN MAKE A SINGLE PAYMENT FOR ALL CAMPERS BELOW)

* Indicates required field

Camper/Teen Counselor Name *

First

Last

Gender *

Male Female

Date of Birth (mm/dd/yy) *

Age *

Grade Completed *

Address *

Father's Name *

First

Last

Father's Home Phone *

Other Phone *

Father's Email *

Father's Employer *

Father's Work Phone *

Other address if camper not residing with both parents *

Mother's Name *

First

Last

Mother's Home Phone *

Other Phone *

Mother's Email *

Mother's Employer *

Mother's work Phone *

HEALTH INFO

Health Insurance Provider *

Physician *

Dentist *

Medical Condition *

Medications *

Does camper attend school in Maryland? (If no submit a copy of immunization record) *

Yes No

Policy Number *

Physician Phone *

Dentist Phone *

Allergies *

Glasses/Contacts *

Yes No

Date of last Tetanus shot (mm/dd/yy) *

EMERGENCY CONTACT (if parent/guardian cannot be reached)

Name *

First

Last

Relationship *

Home Phone *

Work Phone *

Other Phone *

SUBMIT INFORMATION

Pay for all your campers by credit card below.

1st Child

Sibling

Teen Counselor

Aftercare (per week)