Cornerstone Church
CY Summer Camp 2018 - Deposit/Form
Attendee Age
*
Attendee Last Name
*
Attendee First Name
*
Attendee Birthdate
*
Attendee Gender
*
Attendee Address
*
Attendee Phone
*
Attendee Email
*
Attendee Grade
*
Emergency Contact Name
*
Emergency Contact Relationship
*
Emergency Contact Cell Phone
*
Does the attendee have any diseases/physical limitations or any kind?
*
No
Yes
Is the attendee restricted from any activities?
*
No
Yes
Does the attendee have any allergies (Food, Medical, Insect, etc.)?
*
No
Yes
Does the attendee have an EpiPen?
*
No
Yes
Family Physician
Family Physician Phone
Does the attendee take prescription medication?
*
No
Yes
Medication 1
Medication 1 Purpose
Medication 1 Dosage, Frequency Taken, Time of Day Taken
Medication 2
Medication 2 Purpose
Medication 2 Dosage, Frequency Taken, Time of Day Taken
Medication 3
Medication 3 Purpose
Medication 3 Dosage, Frequency Taken, Time of Day Taken
I (adult parent/guardian) have received a copy of the "Youth America Summer Camp Information and Medical Release Form" to complete on behalf of my student.
*
No
Yes
Pay Deposit - $50 (Early Bird Due 2/28/18 by 7pm / Regular Due 5/2/18 7pm) or Pay Full Amount - Early Bird $230 / Regular $250 (Early Bird Due 4/11/18 by 7pm / Regular Due 5/23/18 7pm)
$
Your Email Address
*
Total
$
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