Individual Registration

Please enter information in the form below to process registration for event HIGH SCHOOL RETREAT - August 26-28 (Andy Brazle).

VERY IMPORTANT: Please key in DATE OF BIRTH and all PHONE NUMBERS in the exact format shown by the field name. These fields are critical to processing and communications.

* indicates a required field

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip: *

Home Phone (xxxxxxxxxx): *

Cell Phone (xxxxxxxxxx): *

Emergency Phone (xxxxxxxxxx): *

Email: *

Gender: *

Age at Camp: *

Date of Birth (YYYYMMDD): *

Next Grade: *

NOTE: T-Select a size from EITHER the Youth OR the Adult T-Shirt Size fields. Select NA in the other field.

Parents Name: *

Home Congregation: *

Church City: *

Church State: *

Medical Insurance Co (or NA): *

Insurance Policy Nbr (or NA): *

Insurance Group Nbr (or NA): *

Insurance Id Nbr (or NA): *

Medical Comments/ Requirements/ Allergies (or NA): *

Cabin Requests (or NA): *

Terms & Conditions: By acknowledging the "Terms & Conditions" the parent/guardian authorizes the personal and medical information to be shared with the people that have a reasonable need to know in order to process the camper's information and be aware of medical concerns. In addition, in the event of an accident or injury the camper’s parent/guardian authorizes Green Valley Bible Camp to seek medical or emergency treatment at a local medical facility and agrees to the head lice policy. The parent/guardian also agrees that Green Valley Bible Camp, its Board of Directors, Trustees, Officers or attendants will not be held legally responsible for any such accident or injury or COVID-19 related illness. Parent/guardian also understands that they are expected to sign a GVBC Release Waiver as part of the onsite check-in process. To agree to these Terms & Conditions, type your name in the acknowledgement box below.

Terms & Conditions Acknowledgement: *

REGISTRAR USE ONLY:

VERY IMPORTANT: Please review all the information keyed into one or multiple applications BEFORE CLICKING ON “Process Registration.” Once you click on that you will not be able to make any changes.

Payment Information

Coupon

Amount

Discount Amount

Gross Amount

Payment Method

Paypal

Billing Zipcode*

Credit Card Number*

Expiration Date*

Card (CVV) Code*

Card Holder Name*

Verification code*