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Lighthouse Baptist Camp Registration
July 6-11, 2015
(Everyone attending camp should fill out this form for meal and insurance accountability)
Name: _______________________________________ Male / Female
Age: ________
(please print clearly)
Street Address: ________________________________ Home Phone: ___________________
City/State/Zip: ________________________________________________________________
Contact Person: __________________________ Relationship to camper: ________________
Contact Address:________________________________________ Phone: ________________
è Circle One:
CAMPER
(6TH – 12TH Grade)
Kitchen Helper
Jr.Camper
(child of a helper)
EVANGELIST
COUNSELOR
Jr.Counselor
(Team Leader)
Event Coord.
Size: Adult: S
M
L
XL
XXL
è Shirt
________________________________________
è è
Promotional Release
(age 18 or older)
OTHER______________
Other: _____________
I, ______________________________ the parent of _________________________________
give permission to the director(s) of Lighthouse Baptist Camp to use photographs and/or
videos of my child/camper in promotional camp literature or DVDs used in distribution to
individual campers as keepsakes, churches and/or other interested entities for use in promoting
future camp events or donating financial funding to Lighthouse Baptist Camp. No names or
addresses of campers will be furnished with these promotional distributions.
Parent’s Signature: __________________________________ Date: _________________
è Registration Deadline: Wednesday, June 17, 2015. Late registrants will be subject
to approval based on total number of campers registered. Only 150 camper slots will be available.
è Registration Fee: $100 (includes T-shirt, meals, Camp DVD & transportation for the duration
of event) payable with registration form to:
Lighthouse Baptist Ministries
515 S. 20th St.
Unionville, MO 63565
If you have additional questions you may contact Bro. Chris Wilcox at the above address or by phone at 816-810-5806. If necessary,
please leave a message and your phone call will be returned as soon as possible.
Medical/Liability Release Form on the back of this form MUST also be signed!