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Where the Holy Bible is Wholly Taught

REGISTRATION CARD

Lighthouse Day Camp 2022

July 11th - 15th

     Name:

​_____________________________________________________________________

    Complete Address: __________________________________________________________________________________________________________________________________________________________________________________________________________________

     Home Phone: ___________________________________

     Work Phone: ___________________________________

    Parent/Guardian:

_____________________________________________________________________

     Allergies/Medical Information (What type of reaction? What type of              medication?What time of day? What happens if not taken?) 

 _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

    Birth Date (M/D/Y) ________________________________________________

    Age: __________________________________

    Grade Completed: ______________________

    Brought By: _______________________________________________________

     Church: ___________________________________________________________

  Do you give permission to post your child's picture on our website?  

                                                           Yes      No

   Who will be picking up your child? _____________________________________________________________________