Camper Application

An application is required to be submitted for every camper and pre-camper who wishes to attend JSCYC. Campers are required to have completed the third grade. Pre-campers must be accompanied by a parent. All applications must be signed by a parent or legal guardian. Applications are accepted on a first come/first serve basis as received by the director. Please read all Rules and Regulations before submitting this application.

The fee to attend JSCYC is $60 per camper. If your congregation is covering this fee, please indicate that in the form below. Thank you!

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Prefer a Paper Application? Print one by clicking the icon.

Camper Name(Required)

First Last

Gender(Required)

Male

Female

Parent/Guardian Name

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address City State ZIP Code

T-Shirt Size(Required)

Age(Required)

Date of Birth(Required)

Grade Just Completed(Required)

Please enter a number from 0 to 12.

Answer must be 0-12. Campers must have completed the third grade. Pre-campers must be accompanied by a parent.

Church you attend(Required)

Is camper a member?(Required)

Any restricted activities?(Required)

Please specify restricted activities:(Required)

Is camper allergic to any medication/shots/insect bites/etc.?(Required)

Please specify allergies:(Required)

Date of last tetanus shot, if known:

Does camper have permission to swim?(Required)

This activity is closely supervised.

Required by KY law:

Has camper ever been hospitalized?(Required)

Name of Hospital

Family Physician, Phone Number, and Location

Parent or Legal Guardian Signature(Required)

Camper Companions

You may list one or two (NO MORE) special considerations for camper companions. THESE CANNOT BE GUARANTEED. Please DO NOT list counselor preference.

Will your church congregation be covering the camper application fee?

Application Fee

Price:

Total

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