Girls Camp Registration 2022
Blackstone Valley Stake Girls Camp, July 18-22, 2022 at Zion's Camp (30 Onway Lake Rd, Raymond, NH 03077)
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First Name *
Last Name *
Ward *
Date of Birth *
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DD
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YYYY
Home address, city, state, zip code *
Level for 2022 *
Youth or Adult Leader Email Address *
If youth email address is unavailable, please supply parent/guardian email address
Please indicate which type of email address is listed above *
Youth or Adult Leader Phone Number *
If youth cell phone number is unavailable, please supply parent/guardian cell phone
Please indicate which type of phone number is listed above *
Parent/Guardian Name *
Adult Leaders - list spouse or emergency contact name
Parent/Guardian Phone number *
Adult Leaders - list spouse or emergency contact cell phone number
Parent/Guardian Email Address *
Adult Leaders - list spouse or emergency contact email address
Name of Personal Physician *
Physician phone *
Personal Health Insurance Company *
Health Insurance Policy Number *
Adult Leader Only: In case of an emergency where I am unable to make medical decisions for myself, I understand every effort will be made to contact my emergency contact (listed in previous section). If my emergency contact is unavailable, every effort will be made to contact one of the alternate people listed above. In the event neither can be reached, I hereby give my permission to the licensed health­care practitioner, selected by the adult leader in charge, to secure proper treatment for me, including hospitalization, anesthesia, surgery, or injections of medications. Adult Leader's Type Signature:
List dietary restrictions
Mark all that apply to you:
If you checked off on any of the above, please explain below:
Swimmer Ability *
T-shirt size *
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