2017 Middle School Camp Registration

COST: $35


Student's First Name*:

Student's Last Name*:

Gender*:

Birthdate mm/dd/yyyy*:

Age (on the first day of camp)*:

Grade entering*:

Middle School attending:

t-shirt size:

How did you hear about EPIC's Middle School Camp:


Food or Medical Allergies:
leave blank if none

Medical Concerns:
leave blank if none


Parent/Guardian Information

Parent/Guardian First Name*:

Parent/Guardian Last Name*:

select primary cell
Cell Phone (###-###-####)*:

select secondary cell
Cell Phone (###-###-####):

Home Phone (###-###-####):

Parent/Guardian Email*:

Address*:

City*:

State*:

Zip*:


Emergency Contact Information

Emergency Contact Name*:

Relationship*:

Phone (###-###-####)*:


*PHOTO/VIDEO RELEASE
For privacy and safety, we will not publish names with photographs/videos.
I authorize the use/release of photographs and/or videos that include the INDIVIDUALS NAMED ABOVE for UCUMC use, in print and electronic materials (worship videos, e-mail blasts, church website, Facebook, etc.).

Photo/Video Release Given
Photo/Video Release Denied


*RELEASE: Submitting this on-line form will be the equivalent of signing a paper registration form.
Yes, I agree

Name of Adult filling out this form*:

Date Electronically Signed mm/dd/yyyy*:

Payment via*: Online Check
Due upon registration.

Person making payment (if other than parent):
 



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