Camp 412 Online Registration

Which describes you?
I am a Counselor
I am a Camper

Gender:

First Name

Last Name

Birthday

Age

Street Address

City/State/Zip Code

Name of Parent or Guardian 1

Emergency Contact Name

Preferred Phone Number

Emergency Contact Phone Number

Pastor's Name

Church Name

Name of Physician

Physician Phone #

Insurance Name

Policy #

Special Needs/Allergies/Chronic Diseases/ etc.

Medications

Date of Last Tetanus Booster

Email

Additional Notes/Concerns

Checkboxes
I've read the consent form for Medical Treatment and Liability listed in the next section and accept the terms stated.

* Please note that the consent form for Medical Treatment and Liability will need to be printed out and signed by A parent or legal guardian. THE Form will need to be turned into Camp Leaders. *

Consent for Medical Treatment and Liability

Camp Registration Form

you must include the fee In order to be successfully registered for Camp Hope. The fees are as follows:
Campers - $100.00 per person
counselors - $50.00 per person

The fee can either be paid online or mailed to the following address: 39 s tWIN sT, wEST jEFFERSON, oHIO 43162. if you would like to pay online please click on the link below.
Select the fund "Camp Hope" AND ENTER YOUR NAME OR THE CAMPERS NAMES IN THE mEMO.

Pay Camp Registration Fees