Pre-registration Form

Parent Name / Middle Initial / Last Name

Phone Number

Address

Whom should we contact in an emergency?

Emergency Contact Phone Number

Additional Phone Number for Emergency Contact

Custodial parent or legal guardian

Additional Custodial Parent or Legal Guardian (if applicable)

Camper(s) Information

Child: Name / Nickname

Child: Age

Child: Gender

Male
Female

Child: Grade Level ( Fall 2021)

Name of Child's School

Child: T-shirt Size

Please upload a photo of your loved one who has passed below. Please know that these photos will be used by campers in remembrance activities at their time at camp.
The photo should contain your loved one, but it can include the camper in the same photo as well.
If you are having trouble uploading a photo, please call Annette Burckart at 937.260.6971.

Photo of Loved One

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Additional Photo of Loved One (optional)

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Additional Photo of Loved One (optional)

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Do you have more campers to enroll?

Any child custody issues we should be aware of? Please specify.

Please share any concerns regarding any camper listed above. (special dietary needs, behavior concerns, social concerns)

Event Registration Software by RegFox

Date: Friday, June 25, 2021

Location: Camp Joy Outdoor Education Center

Pre-registration Form

Camper(s) Information