Cornerstone Baptist Church

2009 Summer Enrichment Camp

Pastor Benjamin Lang -- Director

Registration Date: Weeks Attended 2008: « T-shirt Size:

Child’s Name:

Address: Apt #:

City, ST Zip: Home Phone:

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Name Called By: Gender: Birth Date:

Last School: County: Grade for Fall 2009:

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Child’s Family Information

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Father / Male Legal Guardian Mother / Female Legal Guardian

Full Name: Full Name:

Employer: Employer:

Daytime Phone: Daytime Phone:

Email: Email:

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Additional People Allowed to Drop Off and Pick Up Child (must be over 18)

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Name: Phone #: Relation:

Name: Phone #: Relation:

Name Phone #: Relation:

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Child’s Medical Issues

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Current: Past:

(Allergies, Medical

Conditions and

Medications)

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Emergency Contact: Phone:

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WEEKS YOUR CHILD WILL BE AT SUMMER CAMP

First Half of Camp Second Half of Camp

WEEK OF WEEK OF

June 1 › Yes › No June 29 › Yes › No *Camp will be closed July 3, 2009

June 8 › Yes › No July 6 › Yes › No

June 15 › Yes › No July 13 › Yes › No

June 22 › Yes › No July 20 › Yes › No

July 27 › Yes › No

Office Use Only

_________ Registration Fee $ . Check # ______________ Cash ______________

_________ Orientation Attendance _____________________________ Registration Complete