Youth Camp
Location: Glorieta, NM
Date: June 19-23, 2019
Cost: $320 per person
A $50.00 Non-refundable deposit is due at registration.

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Parent's Name *
Parent's Email *
Parent's Phone
Work Phone
Permanent Address
Address during camp
If different from above
Child's Name
Date of Birth
MM
/
DD
/
YYYY
Gender
Clear selection
Age at Camp
General Health
Clear selection
If Fair or Poor, please explain
Date of Tetanus Immunization
MM
/
DD
/
YYYY
Height
Weight
Shirt Size
Clear selection
Grade
Just completed
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Father's Name
Father's Contact #
Mother's Name
Mother's Contact #
Family Doctor
Dr's #
Family Insurance Company
Insurance Phone #
Policy #
Insured's Name
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