Camp Fee: Pre-registered 2 weeks before start of camp: Less than 2 weeks till camp:
First Chance Camp $75 $80
All other camps $150 $160
(camp dates: First Chance, July 5-8; High School, July 9-14; Junior, July 16-21; Mid High, July 23-28)
Age:____Date of Birth:___________________ M_________ F________
School Grade Next Year:_____________________________
Have You Been Immersed? Y________ N___________
Home Phone Number:_______________________ E-Mail:___________________
Amount Enclosed toward Registration:________ Canteen (camp store):____
DATES OF THE CAMP YOU ARE ATTENDING :___________________________________________________
T-shirt size (Please Circle)Youth S M L Adult S M L XL XXL
For Scholarship, please have this signed by the person or organization who is giving the scholarship.
Presented to:_______________________________________________ $__________
Presented by:_____________________________Phone Number:___________________
By signing this scholarship I certify that the above listed organization will supply Camp Koinonia with the dollar amount listed in a timely manner.
~This Form must be filled out and signed by a parent or guardian. Admission to the camp will be denied without doing so.
Camp Koinonia does not discriminate on the basis of race, national origin,sex or handicap
Home Phone____________________Emergency Phone________________________
Date of last tetanus immunization__________
Please answer all questions
1. What restrictions for your child, if any,should be observed in active life.?___________
2. Are there any physical or emotional conditions which call for special attention?______
3. Are there any medical conditions which call for special attention? (I.E. bed wetting,diet, medications,allergies,and Campers with known bee allergies must have their doctor prescribe an emergency reaction kit)___________________________________________________________________
4. Has there been any recent illness, injury or surgery?__________________________
5. Is the camper under the regular care of a physician for any existing physical or emotional condition?
~In the case of accident, illness or emergency, I hereby give my permission for treatment
Name of parent or legal guardian (please print)______________________________
Signature of parent or legal guardian ______________________________
43062 N River Dr, SweetHome, OR 97386
Phone: 541-367-6000, Nick Nott, manager, 541-505-6465
Summer Camp Registration--2017
PLEASE PRINT OUT AND COMPLETE BOTH PAGES OF THIS FORM