ࡱ> molq` f3bjbjqPqP 66::y rrr8<,dZ    =I"6"Y$\hh^YQYZ&&&X & &&& Wrv&T4Z0dZ&_._&_&&YYXdZN$N  1. Full Name: 2. P.O. Box #: Street Address: City, State Zip: 3. Email (Primary): 4. Home Phone (Primary): 5. Cell Phone: 6. Church:  1. Name: 2. Camp: ( Day Camp ( Young Teen 1 ( Trailblazer ( Young Teen 2 ( Guide 1 ( Senior Teen ( Guide 2 3. Date of Birth: ______/______/ 4. Grade this Fall: 5. Gender: ( M ( F 6. Shirt Size: ( YS ( YM ( YL ( AS ( AM ( AL ( AXL ( AXXL 7. Name & address of a friend we can invite to camp: Name: Address: 8. Please send a current picture of the above named camper (if possible). Thanks! 9. Please list two (2) * people you would like to bunk with at camp: ! You must get permission from these two people to list them as bunkmates. *We cannot guarantee this selection! 1. 2. Release of Liability and Medical Consent WHEREAS, the Gateway Conference of the Free Methodist Church makes the Gateway Retreat Center available for campers; and in consideration for the privilege of using the Gateway Retreat Center through its offices, agents and employees, we do hereby remise, release and forever discharge the Gateway Conference of the Free Methodist Church, the Gateway Retreat Center, and all its offices, agents and employees, acting officially or otherwise, from all actions, causes of actions, claims and demands for, upon, or by any reason injury, damage, loss or death which may occur from the use of Gateway Retreat Center. In the case of medical emergency I understand an effort will be made to contact the undersigned person or guardian. In the event I cannot be reached, I hereby give my permission to the physician and/or hospital selected by the camp director to give treatment for my child named herein in the manner to the extent necessary in the opinion of said physician and/or hospital to care for my child. Signed:________________________________________________Date:_________________ Emergency contact if parent cannot be reached:___________________________________ Phone: __________________ Insurance Information: Company:________________________ Policy #: _______________________ Group #:_____________________ Sponsor Name: _____________________ Doctor:_______________________________ Phone:___________________ Tetanus Shot current: YES NO (Tetanus shot is current if given within 10 years.) Medications: NO YES: _________________________________________________________ ------------------------------------------------------------------------------------------------------------------INVOICE 1. Camp Cost (see prices below) Day Camp $25 $25 Trailblazer $140 $140 Guide & Young Teen $165 $165 Senior Teen $125 $125 2. Discount (see discounts below) !Discount: If two or more children from a single family attend, -$10 the oldest pays full price, but the others deduct $10.00. !Pre-Registration Discount: If postmarked before March 15, deduct $15.00. -$15 !Pre-Registration Discount: If postmarkeWar|ʻʻʬt`O>`O>`O>`O> hKh#0CJOJQJ^JaJ hKh#0CJ OJQJ^JaJ& johKh#0CJ OJQJ^JaJ,jhKh#05CJOJQJU^JaJ#hKhI5CJOJQJ^JaJhI5CJOJQJ^JaJh#05CJOJQJ^JaJhAb5CJOJQJ^JaJ#hKh#05CJOJQJ^JaJh#0CJOJQJ^JaJ)jh\hh#0CJOJQJU^JaJ"8Oe  $ $dha$gd $ $a$gd#0 $ $a$gd#0$ $dha$gd $ $dha$gdI$ $da$gdI$ $da$gd#0$ $dha$gd ,d3   $ 2 U V W Y Z [ \ m n r s w x  n p ʸʸۚ{ hq<h#0CJOJQJ^JaJh#0CJOJQJ^JaJhqN5CJOJQJ^JaJhC5CJOJQJ^JaJ#hKh#05CJOJQJ^JaJ hKh#0CJOJQJ^JaJ hKh#0CJ OJQJ^JaJ& johKh#0CJ OJQJ^JaJ+ I | n ~te v$dgd#0 h$gd#0 $ $a$gd#0$ $dha$gd#0 $ $a$gd#0$ $da$gd#0$ $dha$gd#0$  :$dha$gd $  $a$gd#0 $  $a$gd#0 D J & ' NSe,- ^ŷrrӷӦccrThj5CJOJQJ^JaJh#05CJOJQJ^JaJh#05CJOJQJ^JaJh#0CJOJQJ^JaJh#0OJQJ^Jh#05>*OJQJ^J h#05>*CJOJQJ^JaJhCJOJQJ^JaJhACJOJQJ^JaJh#0CJOJQJ^JaJh8uCJOJQJ^JaJ hq<h#0CJOJQJ^JaJ & ' e{,o$ $dh^`a$gdn$ $dha$gdn $ $a$gd#0 $ $a$gd#0 $ Pa$gd Pgd Pdgd#0 _ &F_',h,,$ P!$dha$gdj$ P!$a$gd#0$ P!$dha$gd#0$ P!$a$gd#0 $ $a$gd#0$ $dha$gdn$ $dh^`a$gdn  "%BE[^_bjk>~lx|μμxmbXxh|OJQJ^Jh>*OJQJ^Jhj>*OJQJ^Jhh#0CJOJQJ^Jh#0OJQJ^Jhh#0CJOJQJ^Jhh#0OJQJ^Jh]Jh#0CJOJQJ^J"h]Jh#05>*CJOJQJ^Jh]Jh#05CJOJQJ^J h#05>*CJOJQJ^JaJ hj5>*CJOJQJ^JaJ!, , , ,,,,,",#,$,%,&,',*,4,6,c,e,h,·ڟڐڄtbUFhh#0CJOJQJ^Jh]Jh#0OJQJ^J"h]Jh#05>*CJOJQJ^Jh]Jh#05CJOJQJ^JhjCJOJQJ^JhhjCJOJQJ^Jh|OJQJ^Jho!hj>*OJQJ^Jh>*OJQJ^Jhj>*OJQJ^Jho!>*OJQJ^JUhhjOJQJ^Jhh#0OJQJ^JhCJOJQJ^Jd before May 10, deduct $10.00. -$10 3. Snack Shop - Maximum amount $20.00 (No refunds given) $20 4. C.D. of camp slide show and misc. pictures - $10.00 $10 5. Total TOTAL 6. Enclosed (Pay in full now & avoid registration lines) PAID     h,k,o,p,,,,,,,,,,,,,,,,,,,,,,,-.2ҳvlaVNJNJNJNJHUh jh Uhn5OJQJ^JhE5OJQJ^JhiOJQJ^Jhi5OJQJ^Jh]Jh#05OJQJ^J"h]Jh#05>*CJOJQJ^J"h]Jh#05>*CJOJQJ^Jh]Jh#05CJOJQJ^Jhh#0CJOJQJ^Jhh#0OJQJ^J"hvUh#05>*CJOJQJ^JhvUh#0CJOJQJ^J,,,,,,,,,--22`3b3d3f3$a$gdw$ P!$a$gd#0$ P!$dha$gd#0! Please complete a separate registration form for each camper. Please PRINT: ! Please turn over and complete the Invoice, the Release of Liability, and Medical Consent Form. 222222^3b3d3f3IJĜhn5OJQJ^Jh #hKhA5CJOJQJ^JaJ#hKhA5CJOJQJ^JaJhA&hq<hA5>*CJOJQJ^JaJ hA5>*CJOJQJ^JaJ#hq<hA5CJOJQJ^JaJ 4 0 0:pw/ =!"#$% Ddf  C BA*parent-guardion_infoR1BpJl D$U2 DFBpJl D$U2JFIF``C    $.' 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