St. Mary of Egypt Orthodox Summer Camp 2012
  CAMPER Registration Form (ages 9-17)
  (complete on-screen and submit electronically, OR complete on-screen then print, OR print then write-in)  *Required Fields

Camper's Name      

*Legal first:

     Preferred first:

*Last:

  
*Gender:   Male  Female
*Date of Birth:   Month:   Day:   Year:      Age at camp:
*T-Shirt size:   Youth: Small  Med  Large      Adult: Small  Med  Large  XL
Patron Saint:      Name Day:  Month:   Day:
*Parish:  

*Priest:

*Home Address:
Home Address 2:
*Home City:   *State/Prov:   *Zip:
*Phone:   - -
*Email:   (for confirmation and correspondence)
*Father's Full Name:      Phone: - -
Mother's Full Name:      Phone: - -
Food Allergies:  

If allergies listed, please indicate reactions and treatments needed?

  
Dietary Restrictions:  
Medical Conditions:  
Are there any circumstances or behaviors in your child's life we should be aware of?
   
*Health Insurance:   My child is NOT insured  My child IS insured - Carrier:
 
All visual/audio material posted on the SMEOC website becomes the sole property of SMEOC. Any of this material, with or without only the first name, of the above camper may be posted on the SMEOC website: Agree Disagree
I have read, understand, and agree to all the registration instructions on the website or in the forms package. Enclosed is a non-refundable non-transferable deposit of $75.00 (U.S. funds) made payable to St. Mary of Egypt Orthodox Camp.
 
*Signed: ______________________________________________    *Date: _____/_____/2012
*Print name:    *Relationship to Camper:
 
Send completed registration form and deposit to:

If you will print this form to mail it, do not Submit below  

Electronic submission implies your signature