Your Name *

First Name

Last Name

Date Of Birth *

MM

DD

YYYY

Your Phone Number

(###)

###

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Your Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

This person must be a parent or gaurdian

First Name

Last Name

Parent/Guardian Phone *

(###)

###

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Signature *

By placing your name in this box, it acts as a digital signature. You are stating that you are the parent/guardian responsible for the Student whose name is listed above. By signing, you also acknowledge that any money paid to Mill Road Baptist Church for the purpose of Charge! youth camp is non-refundable.

First Name

Last Name