EmailMeForm
Senior High Canoe Trip
August 2 (4 p.m.)-4
Camper Name
*
First
Last
Gender
*
Please select
Male
Female
Birth Date
*
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DD
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YYYY
Grade in Fall of 2019
*
Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Email
Home Church Name
Home Church City and State
Primary Contact
*
Please select
Mother
Father
Guardian
Primary Contact Name
*
First
Last
Primary Contact Address (if Different from above)
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Primary Contact Home Phone
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-
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-
####
Primary Contact Cell Phone
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-
###
-
####
Primary Contact Work Phone
###
-
###
-
####
Secondary Contact
Please select
Mother
Father
Guardian
Secondary Contact Name
First
Last
Secondary Contact Address (if Different from above)
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Secondary Contact Home Phone
###
-
###
-
####
Secondary Contact Cell Phone
###
-
###
-
####
Secondary Contact Work Phone
###
-
###
-
####
Emergency Contact Name
First
Last
Emergency Contact Relationship to Camper
Emergency Contact Phone
###
-
###
-
####
Size for Free T-shirt
*
Please select
Youth Small
Youth Medium
Youth Large
Adult Small
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Adult Large
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Name
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Name
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