Camper*

Email Address*

Address*

City*

State*

Zip*

—Please choose an option—MaleFemale Gender*

Age*

Last Grade Completed*

Phone*

Other Phone*

Parent Or Guardian Name*

Home Congregation*

—Please choose an option—AdultYouth Adult or Youth T-Shirt*

—Please choose an option—XSSMLXL T-Shirt Size*

—Please choose an option—YesNo Requesting Scholarship?*

—Please choose an option—YesNo Has the Camper been to Camp Meribah Before?*

Camp Week* Day CampMini-MeribahYouth WeekTeen Week

Amount Due Today*

Note

May Camp Meribah use the camper's photo on social media, camp videos and other promotional purposes?* YesNo

I, the undersigned parent or guardian of the above mentioned, a minor, do hereby authorize the Centerville Church of Christ/Camp Meribah Staff to consent to any examination, treatment, and hospital care which is deemed advisable by a physician in the exercise of their best judgment and release Camp Meribah and its staff from all liability. I also understand that summer camp attendance presents a risk of injury or illness due to activities, transportation, and housing with other campers, including COVID-19. By signing below and allowing my child to attend camp, I acknowledge such risks and release Camp Meribah and its staff from liability. I also acknowledge that Camp Meribah is a Christian Camp that operates on Christian characters and values and that my child may be dismissed without refund for any behavior not in accordance with the values of Camp Meribah.

Electronic Signature*

Sign Date*