Teen Round-Up / FREE Camp Wamatochick / Application Form
Teen Round-Up / Camp Wamatochick PRINT THIS APPLICATION AND BRING IT WITH YOU TO CAMP
5101 S. Senator Hwy
Prescott, AZ 86303 580) 252-9105 / 928-778-0571 teenroundup@gmail.com
5101 S. Senator Hwy
Prescott, AZ 86303 580) 252-9105 / 928-778-0571 teenroundup@gmail.com
Child NAME CAMP DATE M FM
ADDRESS CITY STATE ZIP
AGE PHONE #1 PHONE #2 EMAIL
MEDICAL please circle the following that apply heart problems allergies asthma nose bleeds
please list any food allergies or other allergies
Is Tetanus shot up to date? yes / no NAME OF INSURANCE NAME OF INSURED
I hereby give consent for my child to attend Teen Round-Up camp and authorize Director, Roxanne Kerley to seek medical care in case of emergency and I cannot be reached. The free camp is a Christian camp teaching Christian values and offering children a Bible.
Signed Parent or Legal Guardian DATE
www.teenroundup.org Teen Round-Up / P.O. Box 2464 / Prescott, AZ / 86302 Directors: Roxanne Kerley & Calvin Kerley
ADDRESS CITY STATE ZIP
AGE PHONE #1 PHONE #2 EMAIL
MEDICAL please circle the following that apply heart problems allergies asthma nose bleeds
please list any food allergies or other allergies
Is Tetanus shot up to date? yes / no NAME OF INSURANCE NAME OF INSURED
I hereby give consent for my child to attend Teen Round-Up camp and authorize Director, Roxanne Kerley to seek medical care in case of emergency and I cannot be reached. The free camp is a Christian camp teaching Christian values and offering children a Bible.
Signed Parent or Legal Guardian DATE
www.teenroundup.org Teen Round-Up / P.O. Box 2464 / Prescott, AZ / 86302 Directors: Roxanne Kerley & Calvin Kerley