Register

I am registering as a:*

Chaperone Information

Chaperones (1 per 7 students)

Name

First Last

Phone

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Church / Pastor*

If your church isn't listed, please note your church and Pastors name in the comment box at the end of the form and we will add if for next year.

Church / Pastor add request

Please enter church name and pastor's first and last name.

Age*

Please enter a number greater than or equal to 18.

Gender*

Male

Female

Parent/Guardian Information

Parent/Guardian Name*

First Last

Email*

Phone*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Church / Pastor*

If your church isn't listed, please note your church and Pastors name in the comment box and we will add if for next year.

Church / Pastor add request

Please enter church name and pastor's first and last name.

Camper Information

How Many Campers Am I Registering?*

Please enter a number from 1 to 5.

Must live in the same household.

Name of Camper*

First Last

Age*

Please enter a number from 12 to 25.

Gender*

Male

Female

Camper 2 Information

Name of 2nd Camper*

First Last

Age*

Please enter a number from 12 to 25.

Gender*

Male

Female

Camper 3 Information

Name of 3rd Camper*

First Last

Age*

Please enter a number from 12 to 25.

Gender*

Male

Female

Camper 4 Information

Name of 4th Camper*

First Last

Age*

Please enter a number from 12 to 25.

Gender*

Male

Female

Camper 5 Information

Name of 5th Camper*

First Last

Age*

Please enter a number from 12 to 25.

Gender*

Male

Female

Medical Information

Medical Insurance Company*

Cardholder's Name*

First Last

Policy Number(s)

Policy Number

Medications Taken By Camper*

Allergies*

Special Needs

This Box Must Be Checked To Submit Form*

By checking this box, you agree to the below statement, and also give your child(ren) permission to attend StrongTower Youth Camp.

I, as the legal guardian of the above camper(s), give permission to the medical or dental personnel selected by the FAC Maryville administration to order X-rays, routine tests, and treatment for my child(ren), and in the event that I cannot be reached in an emergency, I nearby give permission to the physician or dentist selected by the administration to secure proper treatment for, and to order injection and/or surgery for my child(ren). I further acknowledge that I will be responsible for the payment of all charges related to the medical or dental services for my child(ren). PHOTO/VIDEO RELEASE I hereby give permission for images of my child or myself, captured during StrongTower Youth Camp productions through video, photo and any digital means, to be used solely for the purposes of StrongTower Youth Camp promotional material and publications, and waive any rights of compensation or ownership thereto.

Signature*

Payment Information

Coupon

Registration Cost*

Price:

Registration Cost*

Price:

Total

Credit Card

Cardholder Name

Card Details

Phone

This field is for validation purposes and should be left unchanged.

REGISTRATION OPTIONS

Early

Regular

On-site

Chaperone Information

Parent/Guardian Information

Camper Information

Camper 2 Information

Camper 3 Information

Camper 4 Information

Camper 5 Information

Medical Information

Payment Information