EmailMeForm
Pines Presbyterian Church | Life Camp 2021
Growing with God.
August 2-5 from 9:00AM to 11:30AM
NOTES
Enrollment is limited and acceptance is based on availability at the time of registration. Parents will be notified if camp has reached capacity.
Your child must be 4 years of age and potty-trained (by July 1st) through entering 5th grade in order to participate in Life Camp 2021. There will be a snack time each day.
Please fill out a separate form for each child participating.
PARTICIPANT INFORMATION
Student Name:
*
Name of your home church:
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Antigua and Barbuda
Aruba
Bahamas
Barbados
Belize
Canada
Cayman Islands
Cook Islands
Costa Rica
Cuba
Dominica
Dominican Republic
El Salvador
Grenada
Guatemala
Haiti
Honduras
Jamaica
Mexico
Netherlands Antilles
Nicaragua
Panama
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Trinidad and Tobago
United States
Argentina
Bolivia
Brazil
Chile
Colombia
Ecuador
Guyana
Paraguay
Peru
Suriname
Uruguay
Venezuela
Albania
Andorra
Armenia
Austria
Azerbaijan
Belarus
Belgium
Bosnia and Herzegovina
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Faroe Islands
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Italy
Kosovo
Latvia
Liechtenstein
Lithuania
Luxembourg
Macedonia
Malta
Moldova
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Romania
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
Ukraine
United Kingdom
Vatican City
Afghanistan
Bahrain
Bangladesh
Bhutan
Brunei Darussalam
Myanmar
Cambodia
China
East Timor
Hong Kong
India
Indonesia
Iran
Iraq
Israel
Japan
Jordan
Kazakhstan
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Lebanon
Malaysia
Maldives
Mongolia
Nepal
Oman
Pakistan
Palestine
Philippines
Qatar
Russia
Saudi Arabia
Singapore
Sri Lanka
Syria
Taiwan
Tajikistan
Thailand
Turkey
Turkmenistan
United Arab Emirates
Uzbekistan
Vietnam
Yemen
Australia
Fiji
Kiribati
Marshall Islands
Micronesia
Nauru
New Zealand
Palau
Papua New Guinea
Samoa
Solomon Islands
Tonga
Tuvalu
Vanuatu
Algeria
Angola
Benin
Botswana
Burkina Faso
Burundi
Cameroon
Cape Verde
Central African Republic
Chad
Comoros
Democratic Republic of the Congo
Republic of the Congo
Djibouti
Egypt
Equatorial Guinea
Eritrea
Ethiopia
Gabon
Gambia
Ghana
Gibraltar
Guinea
Guinea-Bissau
Cote d'Ivoire
Kenya
Lesotho
Liberia
Libya
Madagascar
Malawi
Mali
Mauritania
Mauritius
Morocco
Mozambique
Namibia
Niger
Nigeria
Rwanda
Sao Tome and Principe
Senegal
Seychelles
Sierra Leone
Somalia
South Africa
Sudan
Swaziland
United Republic of Tanzania
Togo
Tunisia
Uganda
Zambia
Zimbabwe
Country / Region
Home Phone:
*
###
-
###
-
####
Alternative Phone:
###
-
###
-
####
Mother’s name:
*
Father’s name:
*
Child’s Date of Birth:
*
MM
/
DD
/
YYYY
(month/day/year)
Parent’s email:
*
Grade (or pre-K age) your child will be enrolled in, starting the Fall of 2021:
EMERGENCY CONTACT
Name:
*
First
Last
Phone:
*
###
-
###
-
####
Alternative Phone:
###
-
###
-
####
Relationship:
*
Please list and explain any medical conditions and/or food allergies:
PAYMENT INFORMATION
Registration is $5 per child or $10 per family.
(scholarships are available upon request)
3 options with how you may pay:
1. Complete this form and submit the payment form next (to follow).
or 2. Send Check
Please make checks payable to: Pines Presbyterian Church
Write "Life Camp 2021" on the memo line.
Mailing address:
Pines Presbyterian Church
Attention: Life Camp 2021
12751 Kimberley Lane
Houston, TX 77024
or 3. Bring your completed form and payment to the church office front desk and place in the Christian Education mailbox.
AUTHORIZATION
Today’s Date
*
MM
/
DD
/
YYYY
Your name:
*
has my permission to attend Life Camp 2021 on Aug. 2-5, from 9:00am to 11:30am. I agree for my child’s photograph to be taken and used in future publicity for Pines Presbyterian Church. All personal information about my child will not be disclosed at any time. In the event that I cannot be reached in an emergency, I hereby give permission to the physician or EMT personnel selected to secure and administer treatment, including hospitalization, for the participant named above.
Name of parent or guardian:
*
Insurance company name:
*
Policy#
*
Group #
*
Phone number of insurance authorization:
*
Primary care physician name:
*
Primary care physician phone:
*
###
-
###
-
####
> > > NOTE:
If you're paying online, you'll be automatically directed to the secure payment form after clicking on the "SUBMIT" button (below):
On the next form, please specify:
$5/child
or $10/family