Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Birthday *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Phone *

(###)

###

####

Emergency Number *

Incase of an emergency and we can not get ahold of the first number provided who do we call?

(###)

###

####

Lice Checks *

I understand that Lice checks will be administered at registration and the camper could be SENT HOME if lice are found.

Medical Emergencies *

In case of medical emergency for my child, I understand that Shiloh Bible Camp personnel need the completed Emergency Authorization Form to authorize treatment. By checking the box below, I am agreeing to fill out this form and sign it.

I will sign Shiloh's Medical Release form.

Camp Activities *

My child has permission to participate in all activities on or off the grounds.

Media Release *

I give Shiloh Bible Camp Permission to use photos or video of my family in publications. I release my right to any kind of remuneration for said photo or video.

Payment Method *

Shiloh is not currently accepting online payments. We are sorry for any inconvenience. You can bring it with you when you drop off your child at registration.

I will bring payment when I drop off my child.

Reference's Name *

First Name

Last Name

Phone *

(###)

###

####

Are you willing to follow the Shiloh Bible Camp rules and policies, as well as any directions given to you by the Shiloh Directors, CIT Directors, and Shiloh Board *

Yes, I am willing to follow Shiloh's rules, policies and any direction I am given.