Registration/Payment for Camp Firelight 2024

Number of Kids *

Payor First Name *

Payor Last Name *

Payor Address *

Payor City *

Payor Phone *

Email *

Relation To Child/Children: *

Full Name of Parent / Guardian *

Address of Parent / Guardian *

City of Parent / Guardian *

Postal Code of Parent / Guardian *

Phone # of Parent / Guardian *

Mobile # of Parent / Guardian *

Email Address of Parent / Guardian *

Emergency Contact Name *

Emergency Contact Phone # *

Child 1: First Name *

Child 1: Last Name *

Child 1: Gender *

Child 1: Birthdate *

Child 1: Age *

Child 1: Grade (Fall 2024) *

Child 1: T-Shirt Size *

Child 1: Care Card Number *

Child 1: Allergies/Medication/Health Concerns

Child 1: Doctor's Name *

Child 1: Doctor's Contact Number *

Child 2: First Name *

Child 2: Last Name *

Child 2: Gender *

Child 2: Birthdate *

Child 2: Age *

Child 2: Grade (Fall 2024) *

Child 2: T-Shirt Size *

Child 2: Care Card Number *

Child 2: Allergies/Medication/Health Concerns

Child 2: Doctor's Name *

Child 2: Doctor's Contact Number *

Child 3: First Name *

Child 3: Last Name *

Child 3: Gender *

Child 3: Age *

Child 3: Grade (Fall 2024) *

Child 3: T-Shirt Size *

Child 3: Care Card Number *

Child 3: Allergies/Medication/Health Concerns

Child 3: Doctor's Contact Number *

Child 3: Doctor's name *

Current Church (if attending)

Total Amount

$

Payment procesing fee

$

Gross Amount

$

Payment method

Paypal

Billing Zipcode*

Credit Card Number*

Expiration Date*

/

Card (CVV) Code*

Card Type*

Card Holder Name*

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