CAMP K RETREAT INDIVIDUAL REGISTRATION
Please fill out this form and click submit.
Church Information
City of Church
*
Name of Pastor
*
Pastor's Phone
*
Pastor's Email
Have you received your Senior Pastor's permission?
*
Please select all that apply.
Yes
No
Youth Leader Information
Youth Leader's Name
*
Youth Leader's Phone
*
Youth Leader's Email
Personal Information
Name of Attendee
*
Phone of Attendee
*
Email
*
This address will receive a confirmation email
Parent/Guardian Name
*
Phone of Parent/Guardian
*
Registration
Gender
*
Please select one option.
Male
Female
Select Option
Male
Female
Age Range
*
Please select one option.
Ages 12-18 | Middle/High School
Ages 18-30 | Hyphen
Other (Please describe below))
Select Option
Ages 12-18 | Middle/High School
Ages 18-30 | Hyphen
Other (Please describe below))
Medical History/Comments
Please submit $100 deposit for every person attending.
- $100 Deposit per person due Friday, June 4th
- Remaining $175 per person due Monday, July 19th
Payment
$100
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
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Submit
Description
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