Announcements

 BIBLE STUDY:
This week we will be having Bible Study at Bryan & Karla's home. Normal time of 4:00.  
   
NEW MOON:  The new moon was seen on the evening of Aug. 11th
 

CAMPER'S INFORMATION
First Name:*
Last Name:*
Middle Initial:
Birth Date(mm/dd/yyyy):*
Gender:* Male     Female
Grade in September :*
Age at time of camp:*
Child lives with (check all appropriate):* Mother   Father   Grandparent
One Free T-Shirt :*
My child has attended Messiah West Coast?: * Yes     No
My child's brother or sister has attended Camp ? : * Yes     No
Are there any restrictions on camping activities?: * Yes     No
If there are restrictions, briefly explain:
Do you believe your child may require special services? Yes     No
If so, please indicate the area in which your child may need support.
 
FAMILY INFORMATION
Parent/Guardian #1:*

First:

Last:

Parent/Guardian #2:

First:

Last:

Address line 1:*
Address line 2:
City:*
State:*
Zip:*
Primary Email:*
Second Email:
Home Phone:*
Parent/Guardian #1's Work:*
Parent/Guardian #1's Cell:*
Parent/Guardian #2's Work:
Parent/Guardian #2's Cell:
How did you find out about Messiah West Coast?
If you answered Publication or Other for how you found out about MWC, please specify.
 
DOCTOR AND INSURANCE INFORMATION (Optional)
Family Physician: Name:  Phone:
Family Dentist: Name:  Phone:

Family medical/hospital insurance carrier:
Group #:
Policy #:
Policy holder's name:
   
TRANSPORTATION INFORMATION
Will you need transportation from the airport or bus station? Yes     No
   
EMERGENCY INFORMATION
In the event you cannot be reached, with whom may we consult regarding your child(ren) in an emergency? You must list at least one emergency contact. *

Please specify whether they are a:

  • Stepparent or other adult living in household not listed elsewhere or

  • Name of close friend or relative (who knows he/she has been listed) who has permission and will be available to pick up the camper if necessary.

Contact #1
Name:
Day Phone #:
Cell Phone #:
Contact
Type:
   

Contact #2
Name:
Day Phone #:
Cell Phone #:
Contact
Type:
   

Contact #3
Name:
Day Phone #:
Cell Phone #:
Contact
Type:
 
PAYMENT PLANS
Select your payment plan:* Payment in full  
Pay deposit now. I will pay remainder by June 12th
Send check. Make check out to: "HRBS" and mail to: HRBS 41781 Rd. 142 Orosi, CA, 93647
Pay Later: Submit registration only  
Would you like to sponsor a Camper? Yes     No 
Do you need a sponsor? Yes     No 
   

  
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