Each person should register separately. Select your Group or Organization or, select "none" and then select the program you wish to attend.

*=Required Field

Group/Organization Affiliation*

Please select a Group or Organization affiliation I am attending this event as an individual 29 Palms First Assembly Bargains Thrift Shop Bay Cities Lomita Calvary Chapel Old Towne Canyon Lakes Community Church Canyon Springs Church Clairemont Covenant Church Community Covenant Church (El Cajon) Community Covenant Church (Santa Barbara) Cornerstone Church Covenant Presbyterian Church CrossPoint Christian Church First Evangelical Church of San Gabriel Valley Fountain of Life Covenant Church Grace Community Church Great Commission Church International Hope Christian Fellowship Montecito Covenant Church NewSong Church LA NewSong Church San Dimas Oceanside Christian Fellowship Plymouth Congregation Church Plymouth Congregational Church Redeemer Covenant Church Rolling Hills Covenant Church St. Andrews Presbyterian Church The Village Covenant Church Azusa

Enter optional Group or Organization Name if not found in the list above

Select Program/Event*

Please select a Group or Organization above

Attendee's First Name*

Last Name*

Gender*

Male Female (Used for housing purposes only)

Birth Date

Mailing Address*

Address Line 2

City

State

ZIP Code

Primary Phone*

Secondary Phone

Email*

Parent/Guardian Last Name

Parent/Guardian First Name

Parent/Guardian Relationship

Parent/Guardian E-mail (Put a comma(,) or semicolon(;) between multiple e-mail addresses)

Roommate Request

Activity Restrictions*

Describe any activity restrictions while at camp. Enter "None" if you don't have any.

Diet*

Describe any dietary restrictions or food allergies. Enter “none” if you don’t have any.

Allergies*

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

Medical Treatments* 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? Yes No

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?* Yes No

Medical Restrictions* 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.

Physician:

Prefix

First Name

Last Name

Suffix

Physician's Address

Address Line 2

City

State

ZIP Code

Physician's Phone

Medical Insurance Company

Policy Number