Mountaintop Retreat - Summer Registration

Mountaintop Retreat - Christian Camping, Conference and Retreat Facilities

Camps

Summer Camp Info	Summer Registration
Family Camp

Register early, camps fill up fast!

INSTRUCTIONS

* = required

After submitting this page you will be presented with a printable version of the application. Please print that version, in order to completely fill out the required remaining details.

You will also be provided with a button on that page where you may submit your $10.00 (U.S.) pre-registration fee online, safely and securely, via PayPal

Please contact us directly by email or telephone for non-U.S. address pre-registrations! Contact us if you have any questions whatsoever prior to submitting your online pre-registration information.

Summer Camp Pre-Registration Form

Camper's Name*:

Address*:

City*:

State*:

Postal Code*:

Home Phone*:

Format ###-###-####

Cell Phone:

Format ###-###-####

Camper's Age*:

Camper's Birth Date*:

Month: Day Year

Camper's Gender*:

Male Female

Parent/Guardian
Name(s)*:

Parent/Guardian
Email Address:

Parent/Guardian
Address *:

Is Parent/Guardian
Address Same as Camper?

Yes

Employer Name:

Employer Address:

Church Name* (enter "None" if not applicable):

Emergency Contact Information

Person to Contact in Event of Emergency *:

Phone Number *:

Format ###-###-####

Work Phone Number:

Format ###-###-####

Cell Phone Number:

Format ###-###-####

Name of person(s) who is/are authorized to pickup this child in an emergency or non-emergency *:

Camp Selections

Please select the camp you desire to attend*:

Teen Camp Ages 13 - 18 :: June 11-16
Junior High Camp Ages 11 - 12 :: June 18 - 23
Junior Camp Ages 9 - 10 :: June 25 - 30

Payment Information

Payment Details * (please make a selection):

I will send in the $10.00 Pre-Registration fee and pay the $90.00 balance on check-in day.
I will send in the $10.00 Pre-Registration fee by PayPal and pay the $90.00 balance on check-in day.
I will send in the full $100.00 payment in the mail.
I will pay the full $100.00 check-in day.
I will pay the full $100.00 payment by PayPal
Scholarship

Medical Information

Parent/Guardian, your response to these question will help in the case of your child's illness or injury.

Date and history of any serious illness in the last 12 months.

Date and history of any surgeries in the last 12 months.

Allergies:

Penicillin or other drug reactions:

Special dietary requirements:

IMMUNIZATION RECORD DATES

Diptheria, Tetanus, Pertusis*:	Tetanus, Diptheria*:	Polio*:
Measles*:	Haemophilus influenza type b*:	Mumps*:
Rubella*:	Hepatitis*:	Chickenpox*:

All campers are covered during their stay by Brotherhood Mutual Insurance and subject to the limits thereof. Individual Insurance is primary. Does the camper whose name appears on this form have medical insurance?

Yes No

Health Insurance Information

Campers Insurance Company Name:

Policy Number:

Address:

City, State and Zip:

Telephone:

A completed and signed Registration/Medical/Release
form is required for your child to attend camp.