Student's Name (first, last)
Email Address
Parent(s) Name(s)
Address
City
Zip Code
Home Phone #
Parent Work Phone #
Parent Cell Phone #
Can your Mom or Dad help drive?
Yes
No
How many students can they safely take?
0
1
2
3
4
5
6
7
8
Male
Female
Grade in the Fall
9
10
11
12
School Attending
T-shirt Size
Adult S (34-36)
Adult M (38-40)
Adult L (42-44)
Adult XL (46-48)
Adult XXL (50-52)
Emergency Contact (other than parents)
Emergency Contact Home Phone #
Emergency Contact Cell Phone #
Student Cell Phone #
Medical Insurance Carrier
Policy #
Doctors Name
Parent/Guardian for Medical Treatment:
By inputting my name below, I hereby authorize the directors of Camp Clear Lake to act on my behalf according to their best judgment in an emergency requiring medical attention, and hereby waive and release the camp and church from any and all liability for injuries while at camp.
Space is Limited!!
Registration is not complete until payment has been recieved.
Additional Text here!!!
For further information, call 925.210.9036