subject_line
CCUC Teen Camp 2017
Camper Registration Information
First Name
*
Last Name
*
Date of Birth (##/##/####)
*
+
Gender
*
Male
Female
Street Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
Zip Code
*
Phone Number
*
Email Address
*
Is this the campers first time attending Teen Camp?
*
Yes
No
Grade Just Completed
*
9
10
11
12
Church That Camper or Friend Attends
Emergency Contact Information
In the event of an emergency, who should we contact?
Name
*
Phone Number
*
Relationship to Camper
*
Transportation to Camp
Will the camper require bus transportation to camp?
*
Yes
No
If "Yes," from:
CCUC - Chinatown
Edens Plaza
WCAC - Wheaton Chinese Alliance Church
Special Needs or Medication(s)
Please list any medications the camper is taking and any allergies or dietary needs that he/she may have.
Health Insurance Information
Plan Company and/or Name
Member ID
Group Number