Please fill out, print, and mail in with your deposit. Please use one form for EACH child. Bed space is limited. Register early to avoid disappointment.
Camper's Name: BoyGirl
Head of Household:
E-mail:
Address:City:
State:Zip:
Phone:Camper's Age:T-shirt Size:
Birth Date:Grade Next Year:
Church:
Minister's Name:
I am sending $ for the camp indicated below.
If your church is paying part of your camp fees, indicate the amount here: $
I am registering for the following YOUTH camp:
First Chance Camp (July 8 - 10), $70
First Junior Camp (July 11 - 17), $210
Second Junior Camp (Aug. 1 - 7), $210
Third Junior Camp (Aug. 8 - 14), $210
Jr. High Camp (June 27 - July 3), $210
High School Camp (July 18 - 24, $210
Parent/Guardian Application & Consent Form
Parent/Guardian of Camper: Put FILL in, PRINT, SIGN, then MAIL in with your payment. You must complete and sign this application. Please read the release form carefully.
This application is made with my approval. I shall indemnify and hold harmless Puget Sound Christian Service Camp (also known as Pleasant Valley Christian Camp) and any and all of its personnel of any and all claims of any nature and manner over and above the insurance included in the registration fee, but not limited to the same. I grant my permission for emergency medical treatment deemed necessary by the camp management and attending physician for my son/daughter named .
Signature of Parent/Guardian______________________________________ Date___________
I give permission for photos of my child to be used in promotional items for the camp. Yes No
Insurance Company (Camp is secondary insurer):
Work Phone:
Alternate/Emergency Phone:
Complete the following information.
Is the camper allergic to any food or drugs? Yes No
If yes, explain:
List any medications the camper is currently taking:
When was the last tetanus shot administered?
Does the camp nurse have your permission to administer the following if needed? Ibuprofen (or Aspirin Products) Yes No Tylenol Yes No Over the Counter Allergy Med's Yes No
NOTE: Prescription medications must be sent to camp in their original container.
T-shirts, denim shirts, and other clothing items on sale all summer in the canteen!
Mail completed forms and fees to:
Pleasant Valley Registrar
PO Box 175
Mineral, WA 98355
1-800-789-9841
E-mail: Dan Hamilton
Youth Camp Registration Form