Family Church Bryant

Summer Camp 2024: Thunder in the Desert

Who: Students 7th - 12th Grade
When: July 1st - July 5th, 2024
Where: Spring Lake Camp and Retreat Center - Lonsdale, AR
Cost: $225 per student due June 5th (Non-refundable; non-transferable)
1st Deposit of $125 is due March 27th and remaining balance of $100 is due June 5th
Questions: Yerik Henderson, yhenderson@familychurchbryant.org, Bradley Lattin, blattin@familychurchbryant.org

Camper Information

Full name:

Phone #:

Campers date of birth

Campers Age

Campers gender

Male

Female

Current grade

Camper lives with:

First Name

Last Name

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Parent 2 full name:

Parent 2 email:

Parent 2 phone#:

Group Information

Camper is registering:

As Individual Camper

With a Church Group

Church Name

Senior Pastor's Name

Group Leader Name

Medical Information

Please list any Medical Conditions of the camper. (ex. asthma, diabetes, heart defect, etc)

Please list any Allergies of the camper? (food, insects, etc)

Please list any medications of the camper?

Please list any limitations of the camper? (physical, mental, psychiatric, etc.)

Please list any other details that you feel we need to know?

Emergency Information is required

Physician Name

Physician Phone Number

Do you have health insurance?

Yes

Name of your Health Insurance provider?

Phone Number of Health Insurance?

Name of the Insured person of the Health Insurance?

Group Policy Number of Health Insurance?

Who is the first emergency contact and their cell phone number?

Who is the second emergency contact and their cell phone number?

In case of an emergency, we will contact the parent or legal guardian immediately. If we are unable to reach you, please list a secondary contact person who we can call. This contact must be someone not living in the same household

Permission and Release

This health history is correct as far as I know, and the camper listed above has permission to attend Fired Up For Jesus Winter Retreat and to engage in all camp activities except as noted. I hereby authorize the executive staff or designated medical professional to dispense over -the-counter- medication as needed to the camper listed above.

Parent/Legal Guardian Signature

Payment

Please make all checks payable to Family Church Bryant. You can turn in payments to the church office, Monday-Friday, 8 am - 4 pm. You can make payments online at fcbryant.org/give, please make sure to select TNT Camp under the fund drop down. Remember that final payments are due June 5th, If you are unable to make your payment on June 5th, please contact Pastor Bradley, blattin@familychurchbryant.org or Pastor Y at yhenderson@familychurchbryant.org.

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Summer Camp 2024: Thunder in the Desert

Camper Information

Group Information

Medical Information

Emergency Information is required

Permission and Release

Payment

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