Camper Age Group?*

Kids Camp ($140.00)
Ages 6 - 12
July 11-14
Teen Camp ($165.00)
Ages 13 - 18
July 14-18
Non-Refundable Deposit ($75.00)
Reserve Spot today pay remaining balance at camp.
Church Pays ($0.00)
You register and your church covers the cost. Please make sure you communicate this with your local church.

Camper Name*

Date of Birth*

Are you UNDER the age of 18?*

Yes
No

Address*

Gender*

Male
Female

Church*

Camper Signature*

I, the undersigned, agree to the terms above.

A signed waiver by event participant or parent/guardian will be required before you can download your QR code. A link to obtain waivers for all registrants will be shown on the confirmation page.

INSURANCE

INFORMATION

Insurance Company Name

Insurance ID Number

Primary Physician

Physician Phone Number

Comments

MEDIA RELEASE FORM

I grant permission to the Pentecostal Church of God Southern California District Inc, to use my image (photographs and video) for use in Media publications including but not limited to:

Videos
Email Blasts
Recruiting Brochures
Newsletters
Magazines
General Publications
Website and/or Affiliates
Other

Please select from the following choices:*

I am the parent/legal guardian of the child attending camp.
I am a camper who is 18 years of age or older.

PAYMENT

Convenience Fee

$0.00

Running Total

$0.00

Special Code

Total

$0.00

RegFox Event Registration Software

Event Registration Software by RegFox