On-line Registration. Step
Each person should register separately. Select your Group or Organization or, select "none" and then select the program you wish to attend.
Please select a Group or Organization affiliation
I am attending this event as an individual
Amistad Covenant Church
Anaheim District 2 Church of the Nazarene
Bargains Thrift Shop
Community Bible Church
Cornerstone Church (Palm Desert)
Crossroads Christian Church
Crossroads Community Church (Camarillo, CA)
First Baptist Church of Coachella
First Evangelical Church of San Gabriel Valley
Fountain of Life Covenant Church
Grace Community Church
Greater New Life Christian Church
Green Valley Presbyterian Church
Horizon Community Church
Judson Baptist Church
Life Covenant Church
Mission Springs Community Church
Oceanside Christian Fellowship
Rolling Hills Covenant Church
Solid Ground Church
The Mission Church
The Rock Church
Enter optional Group or Organization Name if not found in the list above
Please select a Group or Organization above
Attendee's First Name
(Used for housing purposes only)
Address Line 2
Parent/Guardian Last Name
Parent/Guardian First Name
(Put a comma(,) or semicolon(;) between multiple e-mail addresses)
Describe any activity restrictions while at camp. Enter "None" if you don't have any.
Describe any dietary restrictions or food allergies. Enter “none” if you don’t have any.
Describe any other allergies. Enter “none” if you don’t have any.
I am 18 or older and choose to decline to provide Health History Information
Describe any past medical treatments relevant to participating in camp activities. Enter “None” if you don’t have any.
Last Tetanus shot
Enter approximate month and year of last Tetanus shot. If for religious and/or other reasons, you choose to not disclose these records please enter "No"
Approx date of last Medical Exam
Are other immunizations current?
If no, please list here
List all medications sent to camp
All medications must be sent in the prescription bottle with label. List all medications sent or enter "None"
May Tylenol, Benadryl, Cough Drops or Tums be administered?
Describe any current medical and/or behavioral conditions that require medications, treatment, or special restrictions while at camp. Enter "None" if you don't have any.
Address Line 2
Medical Insurance Company
I wish to apply for scholarship assistance
Scholarships are based upon income eligibility. Financial information must be complete in order to process scholarships.
Total number of people in household
Total annual household gross income from any source
Use your mouse or finger to draw your signature below
PARTICIPANT PLEASE READ THE FOLLOWING:
By selecting "Submit Form" below, I am registering to attend this camp sponsored by Alpine Camp and Conference Center. I agree to hold harmless Alpine or its agents for any and all claims for injuries, illness, causes of action, the rendering of emergency medical care, or liability related to use or participation in any camp activities. The activities may include, but are not limited to, swimming, ropes course, rock climbing tower, airsoft and all other recreational activities. I agree to the participation in any offsite activities during camp and/or to be transported to and from any offsite activities, or emergency locations, if any, by authorized vehicles. In the event that my Emergency Contact Person cannot be reached in an emergency and I require treatment, I hereby give permission to the physician selected by the camp administration to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for myself. I also give permission to photograph and video myself for any future promotional materials, including Alpine’s website postings, without expectation of compensation.
After selecting "Submit Form" your registration form will be sent to Alpine's camp registrar. To make payments via Visa/Mastercard please call (909) 337-6287 ext 100. If paying by check, please make payment out to "Alpine Camp and Conference Center." Once payment has been received, your registration will be complete and you will receive an email confirmation shortly.
Thank you for your registration! To secure your spot, please call (909) 337-6287 Extension 100 to make a payment.
PO Box 155
Blue Jay, California 92317