Monument Baptist Church
Wednesday, July 17, 2019

Deaf Retreat

For directions and camp rules please visit: www.twinpeaksbiblecamp.org

Check in 8/16, 4:00-6:00pm/ Check out 8/18, 1:00pm

 
Name______________________________
Address____________________________________________________

City____________________ State__________ Zip___________

Phone_____________________ Email___________________________________________________

Additional Family Members Attending:
               Name                                        Age (children)                             Gender
1._____________________        ________________      _____________________

2._____________________        ________________      ______________________

3._____________________        ________________      ______________________

4._____________________        ________________      ______________________

5._____________________        ________________      ______________________

Emergency Contact: __________________________________

Home number_________________ Cell number_________________

Family Physician______________________ Number________________________

Drug or Allergic reactions? ________________________________________________________

Is Tetanus shot current? Please list date(s): _______________________________________________

Any serious illness, operation or injuries? _______________________________________________

Is treatment continuing? __________________________________________________________

Any disabilities or limitations on activities? _____________________________________________

Any necessary special diet? ________________________________________________________

 

STATE REGULATION: All prescriptions*, over the counter medications and supplements MUST be in the original labeled container *from a licensed pharmacy, labeled properly, including the campers name, directions for use and name of the prescribing practitioner.

 

WHAT TO BRING: Bible, notebook, pencil, towels, soap, sleeping bag or blankets, sheets, pillow, jacket, sweater.

 

Costs:  ______ X $60 for weekend (13 and up)                    Please Make Checks out to:   Monument Baptist Church

               ______X $20 for weekend (12 and under)               Send to:         Monument Baptist Church              

Total____________                                                                                              P.O. Box 1327, Grand Junction, CO 81502

 

Questions? Please contact Robin, interpretermom@live.com

PLEASE SEND REGISTRATIONS BY August 5th

To Print Registation Form Press Ctrl+P on Your Keyboard