Youth Camp 2023
August 13th-18th | Located at Riverview Bible Camp in Eastern Washington. Please complete this form to register.
Camper's Information
Camper's Name
*
Age
*
Gender
*
Please select one option.
Male
Female
Birthdate
*
Grade Going Into
*
Please select one option.
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Church Association
*
Please select all that apply.
Family Worship Center
Other/None
Phone
*
Email
*
This address will receive a confirmation email
Allergies (food or other)
Medical concerns
Other concerns (behavioral, emotional, etc...)
Parent/Guardian Information
Parent/Guardian's Name
*
What is your relationship to the child?
*
Please select all that apply.
Mother
Father
Legal Guardian
Grandparent
Other Relative
Family Friend
Address
*
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Phone
*
Secondary Phone
Email
*
This address will receive a confirmation email
Who is authorized to pick child up?
*
Emergency Contact Information
Name of Emergency Contact
*
Phone
*
Relationship to Camper
*
Emergency Release Form
Emergency Release Form: I give my permission to the staff of Family Worship Center to seek medical attention for my child if necessary while participating at Youth Camp. I understand that all necessary precautions will be taken for my child's safety. I will not hold the church, church staff or church volunteers liable.
*
Please select all that apply.
I agree
Doctor's Name
*
Doctor's Phone
*
Insurance Provider
*
Policy Number
*
Payment
T-shirts are included in the camp fee.
Shirt Size (optional)
Please select all that apply.
X-Small
Small
Medium
Large
X-Large
2XL
3XL
Other
Registration
Pay On-Line ($361.11)
Pay On-Site (cash or check) ($0)
Pay On-Line ($361.11)
Pay On-Site (cash or check) ($0)
Amount
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Submit
Description
August 13th-18th
Located at Riverview Bible Camp in Eastern Washington. Please complete this form to register.
×
Please Fix the Following