Fields marked * are required

Child's Name *

Parent/Guardian Name *

Home Address *

City *

Zip *

Home Phone *

Work Phone

Cell Phone

Birthdate (if younger than kindergarten) or grade completing ('07-08 school year) *

Gender *

Boy Girl

Medical or any other information we need to know. (*Please include food allergies.)

Emergency Contact 1 Name *

Emergency Contact 1 Phone *

Emergency Contact 2 Name *

Emergency Contact 2 Phone *

Who may pick up your child at the end of each day? Full name and Phone

Do you attend church? If so, where?

Appointment of Agent (Please fill in the [bracketed] text) * I, [**YOUR NAME HERE**], hereby appoint Trinity Chapel Bible Church as my agent and representative for the purpose of authorizing and consenting to hospital and/or medical treatment of [**CHILD'S NAME HERE**] for any illness or injury that may occur while such person(s) is/are in the care or custody of the agent between the dates of June 16-20, 2008, if I am not immediately available to give such consent.

To agree to the Appointment of Agent above, type "I Agree" below *

OPTIONAL t-Shirt order: t-shirts may only be pre-ordered
with registration. T-shirts are $5 and payment may be made
with registration or on the first day of Camp Trinity. By
indicating a shirt size, you commit to ordering a t-shirt

No Shirt Youth Small Youth Medium Youth Large Small Medium Large X-Large