Counselor & Staff Registration Form

St. Mary of Egypt Orthodox Summer Camp 2012
COUNSELOR & STAFF Registration Form (ages 18+)
(complete on-screen and submit electronically, OR complete on-screen then print, OR print then write-in) *Required Fields

Name
*Legal first:		Preference for nametag (patron saint, Mr/Mrs, Aunt/Uncle...):
*Last:
*Returning Staff?		Yes, I was part of the 2011 CSME staff. No, I did not serve CSME in 2011.
*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)
Food Allergies:
If allergies listed, please indicate reactions and treatments needed?
Dietary Restrictions:
Medical Conditions:
*Health Insurance:		I am NOT insured I AM insured - Carrier:

ALL staff will be expected to attend Staff Training from Friday night, July 13 through Mon, July 16. Due to limited housing and other factors, if you have children coming to camp, separate transportation will need to be arranged, as they cannot arrive until Mon, July 16th. If you have any questions, please contact Director Barbara Schaefer directorcampstmary@gmail.com. I will be available for training: Agree Disagree
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.

Signed: ______________________________________________ Date: _____/_____/2012

Send completed registration form to:

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

Electronic submission implies your signature