Wufoo

Participants Name * First Last
Gender *
Male Female
Grade Complete *
7th Grade 8th Grade 9th Grade 10th Grade 11th Grade 12th Grade Adult / Sponsor
Age of Participant *
Participant email address
Participant Cell Phone Number
Does the Participant use Text messaging?
Yes No
T-Shirt size (T-shirts are adult sized) *
Small Medium Large X Large XX Large XXX Large
Parent or Guardian Name * First Last
Parent or Guardian Home Phone Number *
Parent or Guardian Cell Phone *
Does the Parent use Text Messaging
Yes No
Parent or Guardian Email
How would you prefer to be contacted *
Cell Phone Call Home phone call Text message Email
Parent or Guardian Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Emergency Contact Name *
Emergency Contact Phone Number *
Emergency Contact Relationship to participant *
Medical Insurance Company Name *
Medical Insurance Policy ID Number *
Medical Insurance Group Number *
Does the Participant have any Allergies or Medical Conditions That You Would Like Us To Be Aware Of?
In the event that I can not be reached in an emergency, I hereby give permission to the physician selected by an adult sponsor, or order necessary medical treatements to insure the well being of the above named individual. I also release Simonton Community Church and its employees, sponsors from any accidental liablility *
I agree
The cost for The Student Life Camp is $300.00
The full amount must be paid in full by May 27th, 2012.
You may bring payments to the Youth minister, Chris Saulnier, The Church office, or by mail to:

Simonton Community Church
Youth Camp 2012
Po Box 121
Simonton TX 77476

Financial help is available for those with financial needs. Do not let lack of money keep you from going to the event. *
I will bring my payment I will mail my payment I need to make partial payments I want to go, but need some financial help
Questions or Comments
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