Camp Soubirous Registration

How many campers are you registering?*

Camper #1

Camper's Name*

Gender*

Male
Female

Date of Birth*

MM

DD

YYYY

Rising Grade*

Shirt Size*

Youth:

S
M
L

Camper #2

Camper's Name*

Gender*

Male
Female

Date of Birth*

MM

DD

YYYY

Rising Grade*

Shirt Size*

Youth:

S
M
L

Camper #3

Camper's Name*

Gender*

Male
Female

Date of Birth*

MM

DD

YYYY

Rising Grade*

Shirt Size*

Youth:

S
M
L

Camper #4

Camper's Name*

Gender*

Male
Female

Date of Birth*

MM

DD

YYYY

Rising Grade*

Shirt Size*

Youth:

S
M
L

Parents' Information

Parent #1's Name*

First Last

Parent #1’s Email*

Parent #1’s Cell*

Parent #2's Name

First Last

Parent #2's Email

Parent #2's Cell

Household Information

Home Phone

Home Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Name*

First Last

Emergency Contact Cell Phone*

Home Parish*

PUBLICITY RELEASE*

Permission is hereby granted to St. Bernadette Church to use the voice/audio recordings, photographs, video, and quotations of children and volunteers who participate to assist in community awareness, educational efforts, and related public relations purposes. I hereby agree to release and hold harmless St. Bernadette Church, the Archdiocese of Washington and their agents, servants, and employees from any and all claims, demands, causes of action and/or liability of whatever kind or nature arising out of or connected to the use of said voice/audio recordings, photographs, videos, or quotations.

I hereby waive any right to compensation, fee or royalty for myself, the participant/ student or our successors, heirs, or assigns in connection with the production or use of the aforesaid material.

Agree
Do Not Agree

Parent Signature*

Use your mouse, trackpad or touch screen to sign above.

EMERGENCY MEDICAL TREATMENT

ALLERGIES/SPECIAL NEEDS

Please list any allergies/special needs.

Pediatrician's Name*

First Last

Pediatrician's Address*

City State

Medications (Information for emergency medical treatment)

Total

$0.00

Credit Card*

Card Details

Cardholder Name

2021 Camper Registration

Camper #1

Camper #2

Camper #3

Camper #4

Parents' Information

Household Information

EMERGENCY MEDICAL TREATMENT

Contact Information

Shortcuts

Social Contacts