Camp Refuel Registration Form | Light the Night Ministries

Camper First Name *

Camper Last Name *

Preferred Name (for Name Tag) *

Gender *MaleFemale

School Grade Level (at time of trip) *

T-Shirt Size *

Camper Home Address *Street Address

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Camper Phone #

Camper Email

Camper Church or Youth Group Affiliation

Has Camper Attended Refuel Before? *

Preferred Cabinmate

Emergency Contact Information

Relationship to CamperParent, Grandparent, etc.

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Address *Street Address

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Parent/Guardian Phone # *

Parent/Guardian Email Address *

Medical Information

Health Informationgeneral information we may need to know

Does the camper have any known allergies? *

List Camper Allergies

Does the camper have any special dietary needs? *

List Dietary Needs

Does the camper require any medications while at camp? *

List Camper Medications

Can the camper fully participate in all activities? *

Tetanus Vaccine Date: *

Polio Vaccine Date: *

MMR Vaccine Date: *

DPT Vaccine Date: *

Doctor's Name: *

Doctor's Phone #: *

Media Release

Checkbox *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 agree

Payment

Once complete, please repeat this form for any additional campers you need to register. **Choose Credit Card option if that is how you are paying (ignoring PayPal, unless that is how you intend to pay).

Optional DonationOptional Donation Amount

USD

Total$45 + optional donation above