Grades 10-11-12
June 16-20
(Pre-registration due June 9)

$115.00

Pre-Registration Fee
This form, with check attached must
be submitted by the pre-registration date

$125.00

Day of Camp without pre-registration
Bring this form and a check to the
registration area on the first day of camp.
 

 
 

Important: When this form is submitted, the information will be sent electronically to "pre-register" you.  A new page will be displayed with the information that was entered here in a format suitable for printing.  You MUST print the form, affix the appropriate signatures, and mail it to:

Rev. Brad Reynolds
475 Colliers Way, Weirton, WV 26062

 
Camper's Information
Name:
   
First Last
     
Birth Date:

 

MM/DD/YYYY
     

Address:

  

 

    
City:        
State:        
Zip:        
Email:      
Home Phone:
 

(xxx) xxx-xxxx
   
Emergency Phone:
 

(xxx) xxx-xxxx
   
Church:      
  

By submitting this form, I affirm that I have read the camp rules and will abide by them.  I will give full cooperation to my camp director and staff.  I realize that if I do not comply with these rules, it will result in my being sent home from camp.

 

Parent/Guardian Approval, Waiver of Claim, and Medical Permission

Is the camper allergic to any medication?
Yes
No
If so, what medications?
  
Check if the camper has/has had:            
  Asthma Epilepsy Diabetes Heart Trouble Rheumatic Fever
  

 

General Physical condition of the applicant is:
Good
Poor
   
 

Should the applicant participate in sports?
Yes
No
   
  

 

Is the applicant covered by a Health Insurance Plan?
Yes
No
     

If so, what is the company name?

 

    

Policy Number:

      

Parent/Guardian Social Security Number:

        

 

Important: When this form is submitted, the information will be sent electronically to "pre-register" you.  A new page will be displayed with the information that was entered here in a format suitable for printing.  You MUST print the form, affix the appropriate signatures, and mail it (with payment) to:

Rev. John Keener
137 Mahan Lane
Follansbee, WV 26037