Village Church Burbank

Please fill in the form below to begin your registration for Hume Winter Camp '12. (Counselors please enter N/A in fields that do not apply.)

Choose Your School Level *
I am in High School
I am a counselor

First Name: *

Last Name: *

Date of Birth: *

School: *

High School Graduation Year: *

Address: *

City: *

Zip: *

Parent/Guardian's Full Name: *

Parent/Guardian's Phone: *

Parent/Guardian's Email: *

Student Phone: *

Student Email:

Will you be taking any medication while at camp? *
Yes
No

I am Interested in Financial Assistance:
Yes
No

Amount Needed for Financial Assistance:

My Family would like to contribute towards camp scholarships:
Yes
No

Tell us how you heard about this Winter Camp Event:

I agree to particpate with a positive attitude, be inclusive, follow the rules and be respectful at all times: *
Yes
No

Subject: