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 Amistad Covenant Church Anaheim of the Nazarene Bargains Thrift Shop Bay Cities Lomita Canyon Hills Friends Church Clairemont Covenant Church Cornerstone Church (Palm Desert) Cornerstone Community Church (Wildomar) Crossroads Christian Church (Corona) Crossroads Community Church (Camarillo) First Baptist Church of Coachella First Evangelical Church of San Gabriel Valley Fountain of Life Covenant Church Grace Community Church (Tuscon) Judson Baptist Church Life Covenant Church Living Truth Christian Fellowship Montrose Church Oceanside Christian Fellowship Redeemer Covenant Church Riverview Church Rolling Hills Covenant Church Saddleback Church Solid Ground Church Tesoro Belk Farms The Road

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