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CAMP EDISTO REGISTRATION FORM 2017 (Must complete pages 1 & 2 of this form)

Camp Event / Dates / Dean / Age / Cost
By May 15th / Cost
After May 15th
Senior High
Opens 4pm Sun
Closes 10am Fri / June 11-16 / Larry Bradberry
843-565-3645 / 14-18 / $135 / $160
First Chance
Opens 4pm Fri
Closes 1pm Sat / June 16 & 17 / Jerry Thompson
843-810-8422 / 6 & 7
(And 12 yr old sibling
or parent) / $25 / $35
Junior High
Opens 4pm Sun
Closes 10am Fri / June 18-23 / Chris Gainey
843-696-2090 / 12 & 13 / $135 / $160
Intermediate
Opens 4pm Sun
Closes 10am Fri / June 25-June 30 / David Clanton
843-761-1056 / 10 & 11 / $135 / $160
Junior
Opens 4pm Wed
Closes 10am Sat / July 5-July 8
(Note change) / Maria Brown
803-840-8548 / 8 & 9 / $100 / $120

*All registrations must be received at least one full week before the start of specified camp.*

**Complete pages 1 & 2 of this form & mail form and fee payable to Camp Edisto to:

Larry Bradberry 1165 Betsy Hole Rd Bonneau, SC 29431

CAMPER’S REGISTRATION INFORMATION: MUST FILL OUT, CHECK AND CIRCLE ALL APPROPRIATE INFORMATION

Name ______Male ____ Female ____

Address ______City/State ______

Home # ______Cell # ______

Email ______Zip ______

Birth date (m/d/y) ______Age ______Grade entering ______

Home church ______

Camp attending (circle) Sr Hi Jr Hi Intermediate First Chance Junior

Health Information: Medications currently taking: ______

Health concerns / allergies / etc. ______

List any physical, emotional or mental conditions that could hinder your child from full participation at this week of camp: ______

To the best of my knowledge my child is physically and emotionally able to take part in the camp program. In the event of an emergency, I give my permission for treatment of my child. I will not hold Camp Edisto responsible for accidents or injuries. I have included all appropriate medical information. I recognize this is a Christian camp, and that the Bible will be studied and that camp conduct will be reinforced as consistent with Christian values. I also give permission for the use of photographs / videos including my child to be used in camp publicity.

Signature required: ______(parent or guardian)

Who has permission to pick up camper: ______Phone # ______

PATIENT (PT: CAMPER) INFORMATION

Patient Name ______

First Middle Last

Patient Address ______

Street Apt # City State Zip

Home # ______Cell # ______

Pt Social Security # ______Pt Date of Birth ______Race ______

RESPONSIBLE PARTY INFORMATION (IF OTHER THAN PATIENT)

Insured’s Name ______

First Middle Last

Relationship to Pt ______Date of Birth ______Social Security # ______

Employer Information ______

Address Phone #

INSURANCE COMPANY & POLICY NUMBER

Name ______

Policy # ______Phone # ______

IN CASE OF EMERGENCY, PLEASE CONTACT:

______

First & Last Name Relationship to Patient

Daytime Phone # ______Evening Phone # ______

**Be sure both pages 1 & 2 are completed in full**