The Pentecostals of Mandeville - POM Bible Boot Camp

Parent/Guardian Contact

First Name

Last Name

Email Address

Cell Phone

Spouse/Secondary Contact First Name

Spouse/Secondary Contact Last Name

Cell Phone

Address 1

Address 2

Country

City

State

Zip/Postal Code

Camper #1

First Name

Last Name

Gender
Male
Female

DOB

Age as of July 1, 2022

Camper T-shirt Size

Does your child have any allergies?
Yes
No

If yes, please provide details:

Is your child on any medications?
Yes
No

If yes, please provide details:

Does your child have any illness or disability we should be aware of?
Yes
No

If yes, please provide details:

Camper #2

First Name

Last Name

Gender
Male
Female

DOB

Age as of July 1, 2022

Camper T-shirt Size

Does your child have any allergies?
Yes
No

If yes, please provide details

Is your child on any medications?
Yes
No

If yes, please provide details:

Does your child have any illness or disability we should be aware of?
Yes
No

If yes, please provide details:

Camper #3

First Name

Last Name

Gender
Male
Female

DOB

Age as of July 1, 2022

Camper T-shirt Size

Does your child have any allergies?
Yes
No

If yes, please provide details:

Is your child on any medications?
Yes
No

If yes, please provide details:

Does your child have any illness or disability we should be aware of?
Yes
No

If yes, please provide details:

Camper #4

First Name

Last Name

Gender
Male
Female

DOB

Age as of July 1, 2022

Camper T-shirt Size

Does your child have any allergies?
Yes
No

If yes, please provide details:

Is your child on any medications?
Yes
No

If yes, please provide details:

Does your child have any illness or disability we should be aware of?
Yes
No

If yes, please provide details:

Parent/Guardian Authorization & Release

The Pentecostals of Mandeville reserves the right to use, broadcast and/or publish any photos and/or videos taken during Bible Boot Camp. I further release The Pentecostals of Mandeville and its leaders & volunteers from any claim that my child may have against them as a result of an injury or illness incurred during the course of participation in the activities. In the event of an emergency, I give permission to transport my child to a hospital for emergency treatment. I wish to be advised prior to any further treatment by the hospital or doctor.
I Agree

I agree to pay my T-shirt fee of $12/shirt by Wednesday, June 22nd to The POM app, or by cash or check to the POM.
I Agree

Parent/Guardian Signature (type your name below to sign):

POM Bible Boot Camp

Camper Registration Form

Parent/Guardian Contact

Camper #1

Camper #2

Camper #3

Camper #4

Parent/Guardian Authorization & Release

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