Heritage Youth Camp

What is your full name?

What is your date of birth?

What is your home address?

Parent's Phone Number:

Parent's Email:

Shirt Preference Would you like a short sleeve or long sleeve shirt?

Church Information Do you attend a church?
Yes No

Emergency Contact Name:

Emergency Contact Number:

Do you have medical insurance?

Yes No

First Aid & Consent Agreement

I authorize Heritage Youth Camp staff to seek emergency medical treatment if needed. I assume full responsibility for costs incurred. I also agree to follow all camp rules and hold Heritage Youth Camp harmless in the case of injury or illness due to my own actions.

I agree to the terms above and will follow the camp rules (view camp rules).

E-Signature:

Date:

Camper Registration