Name of Parent(s) or Legal Guardian
Mailing Address
City State Zip
Phone Number Cell Number
Email Address
Emergency Contact Name and Phone Number
Do You attend church? If Yes, where do you attend?
Passport to the World
Camp Harvest
2011 Registration Form
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( Required)
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Child's Name
Grade Last Completed
Age Birthdate
Allergies: Food/Environmental/Medical If any, explain
Child's Name
Grade Last Completed
Age Birthdate
Allergies: Food/Environmental/Medical If any, explain
Child's Name
Grade Last Completed
Age Birthdate
Allergies: Food/Environmental/Medical If any, explain
Child's Name
Grade Last Completed
Age Birthdate
Allergies: Food/Environmental/Medical If any, explain
STATEMENT OF LIABILITY
I understand that all precautions will be taken to avoid injury of my child while in your care. However, if an accident should occur, I will not hold Harvest Community Church responsible. I will signify my agreement below.
Parent/Legal Guardian Name Today's Date
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