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    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)

Name:_____________________________________________Date:________________

Address:_______________________________________________________________

City:___________________________________  State:_______________________

Zip:___________________

Age:____Date of Birth:___________________ M_________   F________

School Grade Next Year:_____________________________

Home Church:________________________________________________________

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:_______________________________________________    $__________

__________________________________________________________Dollars

Presented by:_____________________________Phone Number:___________________

Address:____________________________________________________________

Authorized Signature:_________________________________Date:_______________

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
HEALTH INFORMATION
Name:__________________________________Age____M________F___________

Address:_____________________________________________________________

City_______________________________________State_____Zip_______________

Home Phone____________________Emergency Phone________________________

Physicians Name_____________________________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                  ______________________________



CAMP KOINONIA 
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