Camp Rock 2023 - Camper Registration

July 18th - 21th, 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 Megan Ash at
megan@rockbiblechurch.com.

Child's Name

*

Child's Birthdate (MM/DD/YYYY)

Child's Gender

*

Please select one option.

Male Female

Grade in Fall 2022

*

Please select one 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

Does this child have allergies?

*

Please select one option.

Yes No

If "Yes," please list all allergies

Does this child carry an EpiPen for allergic reactions?

*

Please select one 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

Guardian's Address

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)

Amount

Additional T-Shirts

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

Description

July 18th - 21th, 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 Megan Ash at
megan@rockbiblechurch.com.

Please Fix the Following

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