Camp Soubirous Registration

NOTICE: 1st Grade is now FULL. Please do not register for first grade. To be placed on the 1st grade wait list, please email us at campsoubirous@gmail.com

How many campers are you registering?*

Camper #1

Camper's Name*

Gender*

Male
Female

Date of Birth*

Rising Grade*

Shirt Size*

Youth:

S
M
L

Camper #2

Camper's Name*

Gender*

Male
Female

Date of Birth*

Rising Grade*

Shirt Size*

Youth:

S
M
L

Camper #3

Camper's Name*

Gender*

Male
Female

Date of Birth*

Rising Grade*

Shirt Size*

Youth:

S
M
L

Camper #4

Camper's Name*

Gender*

Male
Female

Date of Birth*

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*

REQUESTS:

Please use this space to inquire about a special request for your camper regarding roster or class placement. Note that spaces are limited and we must maintain our camper to counselor ratios. Plenty of time and care is given to roster assignments. Please understand that not all requests will be granted and rosters will not be changed after registration has closed. Thanks in advance for your understanding.

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

2022 Camper Registration

Camper #1

Camper #2

Camper #3

Camper #4

Parents' Information

Household Information

EMERGENCY MEDICAL TREATMENT

Contact Information

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Social Contacts