Camp Refuel Waitlist Camper First Name *Camper Last Name *Preferred Name (for Name Tag) *Gender *MaleFemaleSchool Grade Level (at time of trip) *Please Select6th grade7th grade8th grade9th grade10th grade11th grade12 gradeadultT-Shirt Size *Please SelectYouth SmallYouth MediumYouth LargeAdult SmallAdult MediumAdult LargeAdult XLAdult 2XLAdult 3XLAdult 4XLCamper Home Address *Street AddressApartment, suite, etcCity *State/Province *ZIP / Postal Code *Camper Phone #Camper EmailCamper Church or Youth Group AffiliationHas Camper Attended Refuel Before? *Yes/NoYesNoPreferred CabinmateEmergency Contact InformationRelationship to CamperParent, Grandparent, etc.Parent/Guardian First Name *Parent/Guardian Last Name *Parent/Guardian Address *Street AddressApartment, suite, etcCity *State/Province *ZIP / Postal Code *Parent/Guardian Phone # *Parent/Guardian Email Address *Medical InformationHealth Informationgeneral information we may need to knowDoes the camper have any known allergies? *Yes/NoYesNoList Camper AllergiesDoes the camper have any special dietary needs? *Yes/NoYesNoList Dietary NeedsDoes the camper require any medications while at camp? *Yes/NoYesNoList Camper MedicationsCan the camper fully participate in all activities? *Yes/NoYesNoTetanus Vaccine Date: *Polio Vaccine Date: *MMR Vaccine Date: *DPT Vaccine Date: *Doctor's Name: *Doctor's Phone #: *Media ReleaseCheckbox *I grant permission for my child’s photograph, video, or likeness to be used by Light the Night Ministries for promotional purposes. This includes posting on Facebook, the organization’s website, and other social media or marketing materials.I agreeJoin Waitlist Submit To Waitlist
