Step 1 – Registration
 

By signing my name below, I do hereby authorize the Woodstock Evangelical Covenant Church to seek emergency medical care for my child(ren) in the event of injury, accident or illness. I give my son/daughter permission to attend the Sr. High Fall Camp Out at Camp Nickerson, Chaplin, CT - September 7-9, 2018

Parent's Name (required)

Street Address (required)

City/State/Zip Code(required)

Phone Number (required)

Parent's Email (required)

Emergency Contact Name 1 (required)

Emergency Contact Phone 1 (required)

Emergency Contact Name 2 (required)

Emergency Contact Phone 2 (required)

Insurance provider and number(required)

May we have your permission to photograph your child(ren)? (required)
YesNo

Child (1) Name

Child (1) Age

Child (1) Grade

Medical/Health/Allergy Concerns (1)

Child (2) Name

Child (2) Age

Child (2) Grade

Medical/Health/Allergy Concerns (2)

Child (3) Name

Child (3) Age

Child (3) Grade

Medical/Health/Allergy Concerns (3)

Payment

Note: If you are submitting payment online, please click the SEND button below and THEN proceed to the payment portion of this form.

 
Don’t forget to click SEND above before moving on to online payment otherwise your registration will not go through.
 
 
Step 2 – Payment