Registration Form
 2017 Kidz Kingdom Summer Camp
Grades K - 5th
start
 
This Camp is for Children Grades K-5 (current) 

Provide Student Information Below
 
Name *

Full Name
 
Male or Female *


 
Birthdate *

 
Current Grade *

 
School *

 
T-Shirt Size *


 
Do You Have another Student to Register?

If you answer Yes, please fill out "Additional Student Info." If you answer No you will automatically be directed to next section.

 
Additonal Student Information

Fill out needed information below.
 
Name *

Full Name
 
Male or Female *


 
Birthdate *

 
Current Grade *

 
School *

 
T-Shirt Size *


 
Do You Have another Student to Register?

If you answer Yes, please fill out "Additional Student Info." If you answer No you will automatically be directed to next section.

 
Additonal Student Information

Fill out needed information below.
 
Name *

Full Name
 
Male or Female *


 
Birthdate *

 
Current Grade *

 
School *

 
T-Shirt Size *


 
Medical Information

Please fill out necessary information by clicking "continue."
 
Does your child/children take any medicine regularly?

If yes, please give details
 
Is your child/children  allergic or sensitive to medicine or inoculations, asthma, hay fever, insect bites, poison oak, any foods, etc.?

If yes, provide answers below.
 
Is your child/children insured? If yes, please provide necessary Information below.

 
Insurance Company

 
Insurance Number

 
Please specify any other information that would be helpful for the adults supervising your youth during this event. (Significant recent illness, accident, health history, etc.) You can use the space below.

 
Parent/Guardian #1 Contact Info

Please provide needed information below. We will only contact for updates and emergencies.
 
Parent/Guardian Name *

Full Name
 
Mobile # *

 
What method of communication would be preferred? *



 
Preferred Address

 
Address *

 
City, State *

 
Zip Code *

 
Parent/Guardian #2 (if applicable) Contact Info

Will only contact for updates and emergencies
 
Parent/Guardian Name

Full Name
 
Mobile #

 
What method of communication would be preferred?



 
Medical Release *

I am the legal parent and/or guardian, and I give him/her permission to participate fully in all Activities. I also release Kingdom Church from all liability while my child is participating in activities. I give Kingdom Church permission to obtain, in an emergency, medical care for him/her in the event I cannot be reached and such is necessary. I understand that every effort will be made to contact me in case of such an emergency. I have completed the entire registration form and agree to share and discuss Retreat Rules with my child
     
 
How many Students are you paying for?

Cost for This Event is $100 for 1; $180 for 2; and $240 for 3.

 
Cost for This Event is $100. 

If You are in need of a Scholarship, please contact Pastor James... Scholarships are always available because of the tremendous generosity of our Kingdom Family!
 
Please enter your Credit or Debit Card number:

 
The CVC number:

(3 or 4 digit security number on the back of your card)
 
The name on your card:

 
Your card's expiry month:


 
Your card's expiry year:


 
If Paying by check, please make out to Kingdom EMC with "Student's Name/s" and "Junior Camp" written in the check Memo.

 
So excited for what God is going to do in your child's life at this event!  If you have any other questions, please Katrina Smith or Pastor James.  
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