2024 Kids Camp Registration Form

Camper Contact Info:

Grade entering Fall 2024:

3rd Grade 4th Grade 5th Grade

Camper's Name

Address

Phone

This address will receive a confirmation email

Date of Birth

Gender

Male Female

Church Camper Attends

Camper's T-Shirt Size *Late registrants are not guaranteed a t-shirt

Camper from your grade that you would like to room with (if possible)

Payment

Parent or Guardian's Name

Parent or Guardian's Work #

Emergency Contact Name

Emergency Phone #

Camp activites not permitted (E.g. swimming, sports)

List any Special Medical Problems or Allergies

Special Dietary Needs

Medical Info (REQUIRED)

Ins. Company

Policy Holder

Group Number

Ins. Phone #

List any medications that will be taken at camp:

Camp Orchardville Liability Release Form

By typing below, I hereby consent to let me child attend and participate in all activites at Camp Orchardville. This includes zip-lining, swimming, and ALL other activities. I give my permission for Orchardville Church and Camp Orchardville to transport my child to and from any camp activities off site. Also, I give my permission for the camp nurse to provide over the counter medication as needed. I understand that every precaution will be taken for the safety and well-being of my child, but in the event of an accident, Orchardville Church/Camp Orchardville along with its staff and volunteers, are hereby released from any and all liability.

Parent/Guardian type name below:

Parent/Guardian Name:

Please notify Orchardville Church at 618-835-2677 within 48 hours if your camper will not be able to attend Camp. This will give us time to notify those on our waiting list.

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

June 9th-12th

Please fill out this form and click submit.

2024 Kids Camp Registration Form

Description

Please Fix the Following