REGISTRATION FORM

CAMP FEE: $350 per child. VENMO: @Epiphany22. Please make a note payment is for Vacation Bible Camp fee.

Student Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Grade

Student Address (add apt # and zip, please)

Home Phone

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Mother's Name

Mother's cellphone

(###)

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Father's Name

Father's cellphone

(###)

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Parent's email

Name of caregiver who will pick up child

First Name

Last Name

cell phone of caregiver

Country

(###)

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Permission for your child to go home alone (yes or no, with name of parent)

Please state student's medical or physical disabilities (allergies, IEP, etc)

Emergency Contact Person name and relationship

Emergency Contact Person Phone

(###)

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