Camp 4-5-6 Rescue Reef

Registration Fee is $25 per child / $50 max per family. This includes dinner each night and one t-shirt per child.

First Name
Last Name
Birthday (m/d/y)
School Grade going into
Street Address
Postal Code
Email Address
Home Phone
Mom's cell phone number
Dad's cell phone number
Date Signed (m/d/y)
Signature - typing your name here signifies authorization.
Emergency Contact Name & Phone
Allergies, Medical Condition, Disabilities

If your child has a food allergy, do you plan to bring your own snack each day?
Other People (adults only) allowed to pick up my child
Friend you want to be with
Church you regularly attend
T-shirt size - Sizes not guaranteed after June 3rd
May we use your child's photo internally? Ex: VBS slide show

For online payment click here. Don't forget to also click submit on this form.

Are Required Fields