Summer Registration Form
Camper Info
* Field is required to process this form
* First Name:
* Last Name:
* Address
* City:
* State:
* ZIP:
* Home Phone:
* School:
* Grade (fall '08):
* Birth Date:
* Age:
* Gender:
Male
Female
Email Address:
Church Info
Do you attend a church?
No
Yes
 
Name:
     
City:
State:
Other Info
How did you hear about Pine Ridge Bible Camp?
My Church
A Friend
Phone Book
Internet
 Other:
Are you a new Pine Ridge camper?
Number of siblings attending (for discount):
None    1   2   3 or more
Name of siblings:

Number of friends you have invited (for discount):

None   1 2    3 or more
*Please note that the discounts above will not be shown below, but will be reflected in the confirmation letter you receive.
Name of friends:
Cabin Pals:
Parent/Guardian Info
* Parents/Guardian Last Name:
* Parent/Guardian First Name:
Add'l Parents/Guardian Last Name:
Add'l Parent/Guardian First Name:
* Address:
* City:
* State:
* ZIP:
* Home Phone:
Work/Cell Phone:
Parents' Email Address:
* Camp Selection
Please select one of the following:
 
Tyke Camper
(1st-2nd Grade)
 
Primary Camper
(2nd-4th Grade)
Junior Camper
(4th-6th Grade)
Teen Camper
(7th-12th Grade)
Freddy's Friends
(Mentally Challenged)
Session
Dates
Oasis
Session 13
August 11-12
(Mon-Tues)
Tyke Camp $60
Choice 1
Session
Dates
Oasis
Session 2
June 16-21
(Mon-Sat)
Junior "Steppin' Up" $240
(5th and 6th grade only)
*Please note that this session is a Ridge Camp.
Session 5
June 23-28
(Mon-Sat)
Primary/Junior $240
Session 7
July 7-12
(Mon-Sat)
Primary/Junior $240
Include Horsemanship class?
($50 extra fee)
No   Yes   
Session 8
July 14-19
(Mon-Sat)
Primary/Junior $240
Session 9
July 21-26
(Mon-Sat)
Primary/Junior $240
Session 10
July 28-August 2
(Mon-Sat)
Primary/Junior $240
Choice 2
Session
Dates
Oasis
Session 2
June 16-21
(Wed-Sat)
Junior "Steppin' Up" $240
(5th and 6th grade only)
*Please note that this session is a Ridge Camp.
Session 5
June 23-28
(Mon-Sat)
Primary/Junior $240
Session 7
July 7-12
(Mon-Sat)
Primary/Junior $240
Include Horsemanship class?
($50 extra fee)
No   Yes   
Session 8
July 14-19
(Mon-Sat)
Primary/Junior $240
Session 9
July 21-26
(Mon-Sat)
Primary/Junior $240
Session 10
July 28-August 2
(Mon-Sat)
Primary/Junior $240


Payment Options and Information
Would you like a camp photo ($6.00)? No    Yes   
Would you like to add Snack Shop and spending money to your child's registration?
If so, please enter the amount in dollars: 		$ .00

*Camp photo and snack shop arrangements can also be made on the first day of camp at drop-off.

 

Selection Summary
Camps Selected  
Amount in USD
$
Camp Photo
$
Snack Shop
$
Discounts
$
Total Amount in USD
$
How will you be paying for this registration?
Online
Check/Other
Would you like to pay in full or make a $75 deposit?
Pay in full now
$75 Deposit only. The remaining balance will be paid later.


*If you choose to pay by check, you will be instructed on sending in your form, along with the check. If you choose to pay online, you will be directed to PayPal, where you can securely make your payment with either your PayPal account, or any major credit card. All online payments will incur a 2.9% handling fee. When a valid email address is provided, you will be sent a registration confirmation regardless of the payment type that you select.

 
* Health Information
* Emergency (2nd) Contact:
* Phone:
* Work/Cell Phone:   
* Family Insurance Provider: * Family Doctor:
State Any Physical Limitations:
List all allergies:
Any health or behavioral concerns?
* Immunizations up to date?
No    Yes   
If no, please explain:
* Do you have any communicable diseases?
No    Yes   
If yes, please explain:
Additional Informaiton (500 char. max):
List Current Drugs and Medications:
Parental Consent

I hearby certify that this information is accurate, and I give my consent for my child to participate in the activities of Pine Ridge Bible Camp; for my child to be transported in camp owned vehicles to and from off-camp activities; for the release of medical records in case of illness or injury; and for the use of photographs and videos including my child to be used in camp publicity. I understand that every effort will be made to contact a parent or guardian of camper in the event of a medical emergency. If I cannot be reached, I hereby give permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for, and to order injections, anesthesia or surgery for my child, as named above. I also give my consent to routine, nonsurgical medical care.
By checking this box, you completely agree to the terms above.


©2008 Pineridge Bible Camp