Camp Soubirous Registration

How many campers are you registering?*
Camper #1
Camper's Name*
Gender*
- Male
- Female
Date of Birth*
Month
Day
Year
Rising Grade*
Shirt Size*
Youth:
- S
- M
- L
Camper #2
Camper's Name*
Gender*
- Male
- Female
Date of Birth*
Month
Day
Year
Rising Grade*
Shirt Size*
Youth:
- S
- M
- L
Camper #3
Camper's Name*
Gender*
- Male
- Female
Date of Birth*
Month
Day
Year
Rising Grade*
Shirt Size*
Youth:
- S
- M
- L
Camper #4
Camper's Name*
Gender*
- Male
- Female
Date of Birth*
Month
Day
Year
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

2023 Camper Registration

Camper #1

Camper #2

Camper #3

Camper #4

Parents' Information

Household Information

EMERGENCY MEDICAL TREATMENT

Contact Information

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