Lake Retreat

* denotes required fields.

Camper Information: (You must fill out and submit this form for each camper)
First Name:*		Last Name:*
Street Address:*		City:*
State:*		Zip:*
Home Phone:*		Day/Cell Phone:
Email:*		Email Again:*
Birthday:*
Grade in Fall '09:*
Gender:*	Male Female
Local Church:		Cabin Partner Request:
		(Not guaranteed)
How/where did you hear about Lake Retreat Camps?:

Parent/Guardian Name(s):*
Phone:*		Alt Phone:
Emergency Contact:*
Emergency Phone:*		Emergency Alt Phone:*
Medical Insurance Co:* (type na if none)		Policy #:* (type na if none')
Insured SSN or ID#:* (type na if none)

Medical History:
Number of known diseases/conditions:*
Asthma:		Diabetes:
ADD/ADHD:		Bed Wetting:
Homesickness:
May the child call home if homesick?:*		Yes No
Known Allergies:

Medications:
(All medications including prescription and all over the counter medicines MUST be checked into the camp medical personnel upon arrival!)
Additional Medical information, if any:

	Payment Information:
*	Visa: MasterCard:
*	Name on Card:
*	Card Number:	Is card # valid?:
*	Exp. Date:	(mm/yyyy)
*	CVV Code:

	Billing Address is different from above:
	Street Address:*		City:*
	State:*		Zip:*

	Camp Photo:	$7
	Camp DVD:	$12
	Only $15 when purchased together!

	Contribute to the Lake Retreat Scholarship fund!
	Send a child to camp, who's family cannot afford to. All donations are tax deductible.
	Scholarship Donation: $

	Scholarship Discount: $

		Find Total
	Current Total:

Comments:

All Participants:
In case of medical emergency, I herby give my permission to the physician selected by Lake Retreat Camp management to secure proper treatment, hospitalization, order injection, anesthesia, or surgery for the person named on this registrationI also give permission for promotional pictures to be taken of my child or I, and be used on Lake Retreat information, including the Lake Retreat Camp website, along with allowing photocopies and faxes to be made of this form.
Type 'YES' to agree and digitally sign:*

You must have a valid credit card # to submit!