Revival Youth Camp Registration

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Camp Date: June 16-19, 2021
Please complete one form per student. This form is for our church records. You must ALSO complete the district form at newmexicostudentministries.com/youthcamp (scroll down and click "Online Registration Here")
Be aware that the district now requires a $20 deposit for each student
For any additional questions please contact us at revivalyouth124@gmail.com or text 505-377-7893 (Pastor Ben)
Please save my contact info if you don't already have it
Thank you! We're so excited to bring your students to camp!!
-Pastor Ben & Gabi

Student Name and Age *

Parent/Guardian Name(s) *

Parent/Guardian Preferred Phone Number & Email *

Emergency Contact Name *

List one person we can reach in case you cannot be contacted

Emergency Contact Phone Number *

Student Allergies?

If none, leave blank

Student Medication Requirements?

Please list medication name(s), dosage, and how often it must be taken. If none, leave blank

Any special requirements your student(s) may need?

If none, leave blank

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