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REGISTER ONLINE: REGISTRATION www.lakeanncamp.com Parents or Guardians: Please complete in entirety. CAMPER INFO Carper Fa Wars eg ay Sai6 or Fone Poe aro Ea “Conan wi be Soto PART E-TaH Taes USPS guested Tove ET] Canpar Ena Baie Year FS Graton ‘Gad overng FAT 2005 ‘Gabi We Request Se request per camper, ota aque we UNTER aga Gaarian 1 FTN laionatip Caner We Prone Cal PhaTe | aia Fa Name Raanaip Canpar ‘Wen Pane CalPERS ‘Ger "Pass ten tls curs ra your camper willbe aiendng] Cnet Cy How did you hear about Lake Ann? | DTV ORedo CMali Kiosk Brochure Rack CChuch OFriend Web ChNewspaperMegazine Ad other __ Please Check the dates and camp program requested: HEALTH INFO Fam Dactor Dados Pane Trsurance Company PORTE Tease Tal any GuTentIfSCIOUS ARaSOT OF CORAHIORE = ‘Please Ia any acivies Tom which Camper SROUd be exam Tar Peal reasons raase Tat any physical, Menta, Or paychaToaTeaTcondlions requiring medication, Woalmant epacalrestrclions or consideration wile al camp, reas Tat any past meceal PaatrenT Proasi Tis campars inmurizaiions Date OTe Tetanas Shot Please Ist campers current medications, bol presciibed and over-the-counter (Mdlaallons Gant a Camp Ria Ba Th OFgiraT container] Plaase ist camper’ allrgis (bee sbngS, 1000, TCT. raaie lat any det reaiaions Please epeciy any other Medical cancers Tor your IK, On the rare occasion that a camper must be transported to the hospital, parents will be notified as soon as possible. ‘SECURITY/PAYMENT INFO {inca of made cman grea ede! ae | he ens fr mel oat fy yh mada by ethan pron. Te cap Cares sind ctr iar, Hp ‘mera mst sted oe panacea fn pa acy be sate crc area an wt ac ry case [cal peated Siew wou wien tatetin baud wh can capresso cy bon co et my fam ooo are paca moves: Fe {Simao iranayn my ote ane fas male my eomp par etary nab ak a are amazon Ma wa ea Wyner sx nan {D1 authorize the camp to release my child to an authorized representative ofthe church listed above. 1D) authorize the camp to release my chil tothe folowing individuals’ Coheck Visa Mastercard a cade Expraton Date Tag SCT Cale Signalure of Parent or Guan az [esto Cam (600 chart above) Early Bird Discount Dec. 25 Family Friendly Discount Child # March 16 SAVE! With our Family Friendly Discount! Subtract $100 for Child #3 and $150 for all additional children! Child and Child #2 are Deere ‘Amount Enclosed ($126 registration fee required Balance Due Ganscrin a pon aa eae en yO et ae