Camp Rock 2022 - Camper Registration
July 25th - 29th, 9am-Noon | Rock Bible Church
4100 First St
Pleasanton, CA 94566
Please complete a form for each Camper.
To be guaranteed a t-shirt,
Campers must be registered
and paid by Sunday, July 10th!
Questions?
Email Brent Baldwin at
kids@rockbiblechurch.com.
Child's Name
*
Child's Birthdate (MM/DD/YYYY)
Child's Gender
*
Please select one option.
Male
Female
Select Option
Male
Female
Grade in Fall 2022
*
Please select one option.
Pre-K
T-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
Select Option
Pre-K
T-K
Kindergarten
1st
2nd
3rd
4th
5th
6th
T-Shirt Size
Please select one option.
Child XS (2/4)
Child S (6/8)
Child M (10/12)
Child L (14/16)
Child XL (18/20)
Adult XS
Adult S
Adult M
Adult L
Select Option
Child XS (2/4)
Child S (6/8)
Child M (10/12)
Child L (14/16)
Child XL (18/20)
Adult XS
Adult S
Adult M
Adult L
Does this child have allergies?
*
Please select one option.
Yes
No
Select Option
Yes
No
If "Yes," please list all allergies
Does this child carry an EpiPen for allergic reactions?
*
Please select one option.
Yes
No
Select Option
Yes
No
Child's Medical Provider
*
Child's Medical ID #
*
Name of a friend your child would like to be grouped with
Guardian's First Name
*
Guardian's Last Name
*
Guardian's Relationship to the Child
*
Please select one option.
Parent
Grandparent
Relative - other
Close Family Friend
Select Option
Parent
Grandparent
Relative - other
Close Family Friend
Guardian's Address
--
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Guardian's Email
*
This address will receive a confirmation email
Guardian's Phone Number
*
Emergency Contact Phone Number
*
Registration & T-Shirt
Online - preferred ($80)
Via check ($0 now)
Wed-Fri ($48)
Thurs-Fri ($32)
Fri ($16)
Online - preferred ($80)
Via check ($0 now)
Wed-Fri ($48)
Thurs-Fri ($32)
Fri ($16)
Amount
Additional T-Shirts
None ($0)
1 Extra ($10)
2 Extra ($20)
3 Extra ($30)
None ($0)
1 Extra ($10)
2 Extra ($20)
3 Extra ($30)
Amount
Credit/Debit Card Number
Expiration Date/CVC
Name on Card
Card Billing Address
AA
AB
AE
AK
AL
AP
AR
AS
AZ
BC
CA
CO
CT
DC
DE
FL
FM
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MB
MD
ME
MH
MI
MN
MO
MP
MS
MT
NB
NC
ND
NE
NH
NJ
NL
NM
NS
NT
NU
NV
NY
OH
OK
ON
OR
PA
PE
PR
PW
QC
RI
SC
SD
SK
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
YT
Submit
Description
July 25th - 29th, 9am-Noon
Rock Bible Church
4100 First St
Pleasanton, CA 94566
Please complete a form for each Camper.
To be guaranteed a t-shirt,
Campers must be registered
and paid by Sunday, July 10th!
Questions?
Email Brent Baldwin at
kids@rockbiblechurch.com.
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