Fall Youth Camp
Registration Form
Oct. 27th thru Oct. 29th
ALL APPLICATIONS MUST BE RETURNED
BY SEPT. 30th, 2011 WITH 1/2 OF THE FEE.
SUMMER CAMP FEE IS $50.00

 

CAMPER NAME: _______________________________

PARENTS NAME:  ______________________________

ADDRESS: _____________________________________

CITY: ________________ STATE: ______ ZIP: _______

HOME PHONE#: _______________________________

OTHER PHONE#: _______________________________

E-MAIL: ______________________________________

GENDER: _____ DATE OF BIRTH: _________________

AGE: _________    T-SHIRT SIZE: ____________

ALLERGIES: ______________________________

MEDICINE: _______________________________

 

IN CASE OF EMERGENCY, NOTIFY:

NAME: ________________________________________

RELATIONSHIP: ________________________________

PHONE #: ______________________________________

 

MAIL TO:
ANTIOCH YOUTH CAMP
c/o Kristi Nunley
19479 N Fork River Road
Abingdon, VA 24210