Camper Application

Please complete the form below to submit the application. Campers must have completed the third grade to attend JSCYC.

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)

Campers must have completed the third grade.

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.

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.

Application Fee

Application Fee Total

Please use card 4242 4242 4242 4242 as the test credit card along with a future expiration date and any CVC code.

Credit Card