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REGISTRATION FORM NC NAZARENE

* T-Shirt Size (adult ) __s __m __l __xl JUNIOR CHILDRENS CAMP (GRADES 4 - 6 ) NAME______

ADDRESS______

CITY______STATE___ ZIP_____

PHONE ( ) ______

MALE_____ FEMALE_____ 4-6 ______LOCAL CHURCH______

AMOUNT ENCLOSED $______

PARENT'S SIGNATURE______“CRU’SIN”

Registration Fee of $5.00 (non-refundable) must accompany this application. Make checks payable to NC Nazarene Junior Camp. David & Lisa Turner August 1-5 PLEASE MAIL FORM TO: COST: $125 per person Rhonda Goe Location: 8118 Hunley Ridge Rd Victory Mountain Camp Matthews, NC 28104 (Formerly Wesleyan Youth Camp) [email protected] 3592 Youth Camp Road Sophia, North Carolina 27380 (Just off County Road #1004 Between Asheboro and Archdale) Rev Reed T Goe, Children's Camp Director (704) 906-2485 or 893-0146 *N.C. Nazarene camps are open to all campers regardless of race, color, sex, religion, national origin, or handicaps. FEE REDUCTION: MEDICAL INFORMATION There will be a $25.00 fee reduction for worker's children. All such applications should have a note to that effect. NOTE: ALL WORKERS MUST SUBMIT A WORKER'S APPLICATION. CHILD'S NAME______LATE APPLICATIONS In order to provide proper planning, supervision, and preparation ADDRESS______for each child, late applications CANNOT be accepted after the July 27th deadline. ______

FOR PARENTS PARENT'S NAME______ A nurse will be on duty at all times  Qualified counselors and instructors PHONE (HOME)______WORK ______ Lifeguard also provided NAME OF MEDICAL INSURANCE______ District Insurance is secondary coverage, supplemental to INSURANCE CARRIER______your primary coverage POLICY NUMBER______ARRIVAL AND DEPARTURE TIMES NO EARLY ARRIVALS, PLEASE! DOCTOR'S NAME______PHONE______Arrival Time: 10:00 AM on Monday, Aug 1 st. First meal will be hot and served at 12:00 PM Have or subject to: (check if YES) Campers will be dismissed after the noon meal on Friday, Asthma_____ Convulsions___ Heart Trouble___ Aug 5th. Parents are urged to arrive by noon Friday. Diabetes____ Fainting______

CAMPERS SHOULD BE PICKED UP BY 12:00 PM. Allergy or reaction to any medication? Describe______ITEMS TO BRING ______ Bible, Pen, Notebook  Casual Clothing/Tennis Shoes/Swim Suit Any condition now requiring regular medication?______ Personal Grooming Items/Towel/Wash Cloth ______ Sheets, Pillow or Sleeping bag Any restrictions of activity for medical reasons?______WHAT NOT TO BRING ______Cell Phone, Radio, Cassette Player, Knife, Fireworks, and / or anything ______you know you shouldn't. I hereby give my approval for emergency medical treatment by proper medical authorities necessary for my child. PARENT OR GUARDIAN SIGNATURE:______

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