Registration

Camp Fee:

Pre-registered before June 15

After June 15

First Chance

$62.50

$72.50

All Others

$125.00

$135.00

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 E-mail: campkoinonia.net

Registration Summer Camp 2010

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