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?	*
Is the attendee restricted from any activities?	*
Does the attendee have any allergies (Food, Medical, Insect, etc.)?	*
Does the attendee have an EpiPen?	*
Family Physician
Family Physician Phone
Does the attendee take prescription medication?	*
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.	*
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	$