Life Youth Camp Registration 2025

Please fill out this form and click submit.

Student's Name

*

Student's Grade

*

Student's Phone (if applicable)

Student's Email (if applicable)

Student's Address

*

Parent 1 Name

*

Parent 1 Phone

*

Parent 1 Email

*

This address will receive a confirmation email

Parent 1 Address

*

Parent 2 Name

*

Parent 2 Phone

*

Parent 2 Email

*

This address will receive a confirmation email

Parent 2 Address

*

Emergency Contact Name

*

Emergency Contact Phone

*

Secondary Emergency Contact Name

*

Secondary Emergency Contact Phone

*

Is the student in need of a camp sponsorship? If yes, please select zero from payment dropdown

*

Please select one option.

Yes No

Does your student take any prescription medication

*

Please select one option.

Yes No

Please list any allergies your student has

*

Does your student require an epi pen or inhaler?

*

Please select one option.

Yes No

Does the camp staff have permission to give any of the following medications? Please check all that apply.

*

Please select all that apply.

Tylenol Ibuprofen Benadryl

T-Shirt Size

*

Please select one option.

X-Small Small Medium Large X-Large XX-Large

Photo Release

*

Please select one option.

I authorize Life Church to use photos of above student for future advertising and event recaps, etc. I DO NOT authorize Life Church to use photos of above student for future advertising and event recaps, etc.

Payment

Student Cost for First Child ($100.00) Student Cost for Second Child ($75.00) Student Cost for Third Child ($50.00) Sponsorship ($0.00)

Amount

Credit/Debit Card Number

Expiration Date/CVC

Name on Card

Card Billing Address

Description

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