Camper Registration

Welcome

Thank you for choosing Camp Perea! We can't tell you how excited we are to have you or your teenager participate in all that is going to happen this week. It will truly be a life changing experience. Once you pay in full you will lock in your rate for Camp Perea, however just your completed registration form does not hold your payment spot. If you have any questions don't hesitate to contact us! Send your questions to Jens at: JSundem@PereaMinistries.org, also feel free to call Jens at 406.381.2793. Remember, full payment is what holds locks in your cost for camp.

First 5 campers: $75
Campers 6-10: $100
Campers 11-15: $125
Campers 16-20: $150
Campers 21-25: $175
Campers 26-30: $200
Campers 31-35: $225

Camper Information

Full Name: *

Home Phone: *

Email Address: *

Home Address: *

City: *

State: *

Zip Code: *

Grade: *

Birthdate: *

Height: *

Gender: *

Age: *

Parent/Guardian Name(s): *

Same Tent:

If you would like to request to be in the same tent with another camper please list their name(s) here:

Emergency Contact Name: *

Emergency Contact Number: *

Permission

Promotional Release

Select Your Preference:

Please do not use my child in any promotional material for Camp Perea

You have my permission to use my child in promotional material for Camp Perea

Because we may be using film footage and pictures from camp for promotional purposes (brochures, website, promotional videos etc.). Please state, if you do or do not release pictures/film footage of your child to be used for promotional purposes.

Health and Medical Information

Primary Care Physician: *

Physician Phone Number: *

Insurance Company: *

Health Insurance ID #: *

Health History: *

	yes	no
Heart Problems
Low or High Blood Pressure
Allergies (if yes, please describe below)
Asthma
Back Problems
Recent Sprains, Fractures or Dislocations
Knee Problems
Dizziness/Fainting Spells
Emotional Impairment or Disability
Diabetes
Epilepsy or Convulsions

Other health issues we should know about or further explanation?:

Medical Release

Consent for Treatment: *

In the event that my child becomes ill or sustains any injury while in the care of or under the supervision of Perea Ministries they are given permission to administer first aid for his/her relief. Consent is also given to admit him/her to any hospital and for all medical, surgical, diagnostic, and hospital procedures and treatment as may be performed or prescribed, including the administration of such drugs or medicines by a physician for him/her when such treatment is deemed immediately necessary, or advisable to safeguard my child's health and it is not advisable or practical to return him/her to us or to receive our instruction on his/her care. I waive my right to informed consent.

Payment

We want to give you options as far as payment goes. You are not required to submit your payment with your registration. But keep in mind that to lock in your rate for Camp Perea you do have to pay in full.

Select One: *

I will be sending my payment via check in the mail.

I would like to pay with Credit Card or Debit: Please send me the secure link to PayPal.

Other, please contact me.

I would like information about financial scholarships. Please contact me.

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