campporter_register – Greater Community Temple COGIC

REGISTRATION DETAILS:

**ALL OF THESE BELOW ARE REQUIRED PER CHILD**.

Registration is $100 
per child

One-Time Activity Fee is $75 
per child

Weekly Tuition is $100/week 
per child

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PARENT OR GUARDIAN'S FULL NAME *

HOME PHONE *

EMAIL OF PARENT OR GUARDIAN *

Email

Confirm Email

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

CHILD'S NAME *

Confirm Registration for this child by checking box below: *

Confirm - $100.00

Confirm One-Time Activity Fee for this child by checking box below: *

Confirm - $75.00

CHILD'S BIRTH DATE *

AGE *

GRADE *

SCHOOL *

Does your child have any allergies (seasonal, food, etc.)? *

Yes
No

Does your child have any medical issues? (Explain Below)

List preferred Hospital or Medical facility for this child in case of medical emergency:

If answered "Yes" above, please list allergy here

Other information needed to ensure the proper care of your child:

MOTHER'S NAME *

FATHER'S NAME

MAIDEN NAME (SECURITY PURPOSES) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

MEMBER OF GCT? *

Yes
No

HOME PHONE *

WHERE EMPLOYED *

BUSINESS ADDRESS

BUSINESS PHONE

BUSINESS EMAIL ADDRESS *

FATHER'S NAME *

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

MEMBER OF GCT?

Yes
No

HOME PHONE *

WHERE EMPLOYED

BUSINESS ADDRESS

BUSINESS PHONE

BUSINESS EMAIL ADDRESS

ARE PARENTS DIVORCED OR SEPERATED?

CHILD RESIDES WITH: *

FATHER
MOTHER
BOTH
OTHER

ARE PARENTS DIVORCED OR SEPERATED?

DIVORCED
SEPERATED

WHICH PARENT HAS CUSTODY OF CHILD? *

ADDITIONAL CHILDREN

ARE YOU REGISTERING ANY ADDITIONAL CHILDREN? *

Yes
No

HOW MANY ADDITIONAL CHILDREN ARE YOU REGISTERING? *

There is a 10% discount per additional child. For each additional child there will also be required a $75 one-time Activity Fee per child.

Child's Name (2nd Child) *

First

Last

Age *

Child's Birthdate *

Grade *

School *

Food Allergy?

Indicate the allergy(s) that this child has, if there are any.

Does your child have any medical issues? (Explain Below)

Preferred Medical Facility in case of emergency for this child:

Child's Name (3rd Child) *

First

Last

Age *

Child's Birthdate *

Grade *

School *

Child Allergy?

Indicate the allergy(s) that this child has, if there are any.

Does your child have any medical issues? (Explain Below)

Preferred Medical Facility in case of emergency for this child:

Child's Name (4th Child) *

First

Last

Age *

Child's Birthdate *

Grade *

School *

Child Allergy?

Indicate the allergy(s) that this child has, if there are any.

Does your child have any medical issues? (Explain Below)

Preferred Medical Facility in case of emergency for this child:

Child's Name (5th Child) *

First

Last

Age *

Child's Birthdate *

Grade *

School *

Child Allergy?

Indicate the allergy(s) that this child has, if there are any.

Does your child have any medical issues? (Explain Below)

Preferred Medical Facility in case of emergency for this child:

Activity Fees

Confirm Activity Fee for 1 Additional Child. *

Confirm Activity Fee for 2 Additional Children *

Confirm Activity Fee for 3 Additional Children *

Confirm Activity Fee for 4 Additional Children *

NAMES(S) OF PERSON(S) OTHER THAN PARENT(S) AUTHORIZED TO ACT FOR PARENT IN CASE OF EMERGENCY:

NAME

HOME PHONE

RELATIONSHIP

WORK PHONE

NAME

HOME PHONE

RELATIONSHIP

WORK PHONE

NAME

HOME PHONE

RELATIONSHIP

WORK PHONE

T-Shirts

Select T-Shirts Required Below

Do you require Tshirts? *

How many tshirts?

Selected Value: 0

Tshirt 1 *

Tshirt 2 *

Tshirt 3 *

Tshirt 4 *

Tshirt 5 *

Terms and Conditions *

I understand that those supervising camp activities will exercise a reasonable degree of care. Therefore, I release the director, staff, Bishop Brandon B. Porter, Greater Community Temple, Greater Community Learning Academy and the camp from all liability, and waive any claim against them for any harm or injury which may be sustained by my child while attending Camp Porter. Furthermore, I assume total responsibility for my child’s conduct during his/her attendance at Camp Porter or related trips and activities.

“I hereby consent to release for possible publication of my child’s name and/or photos and video images taken by any authorized Camp Porter representative or employee. This may include television, newspaper, magazine, and/or social media websites." *

Yes, I authorize
No, I do not authorize

Square *

Card

Name on Card

Total

$0.00

ADDITIONAL CHILDREN

Activity Fees

T-Shirts

We Are Preforming Minor Maintenance! Will return shortly!

We Are Preforming Minor Maintenance!
Will return shortly!