Registering by July 3rd is helpful for planning purposes. First Name *Last Name *Street Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Camper's Gender *FemaleMaleCamper's Birthday *MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Camper's Parent(s) or Guardian(s) *Parent's Email AddressPhone Number for Parent or Guardian (best number to reach you at in case of an emergency) *Family DoctorFamily Doctor Phone Number *Church that the Camper Attends?Camper has been Baptized into Christ?YesNoPreacher's NameCamper has permission to go SWIMMING?YesNoCamper has permission to go BOATING?YesNoWhen did the camper have his/her last TETANUS shot?MonthSelect month123456789101112DaySelect day12345678910111213141516171819202122232425262728293031YearSelect Year212421232122212121202119211821172116211521142113211221112110210921082107210621052104210321022101210020992098209720962095209420932092209120902089208820872086208520842083208220812080207920782077207620752074207320722071207020692068206720662065206420632062206120602059205820572056205520542053205220512050204920482047204620452044204320422041204020392038203720362035203420332032203120302029202820272026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924Does the camper have any ALLERGIES?Is the camper on any MEDICATION?Health insurance company *Health insurance policy number *DIGITAL SIGNATURE OF PARENT OR GUARDIANStart signing your signature hereYour browser does not support e-Signature field.by signing this indicates all information submitted in this form is correct AND that in the event that you cannot be reached for consent, you hereby authorize Gela Goin, Melissa Goin, or David Goin (director of the Little Egypt Christian Youth Camp) or the camp nurse to give consent to a physician of their choice to render any necessary emergency medical treatment in case of illness or accident. This is important since hospitals & doctors will not give emergency treatment without consent of a parent or guardian.Register