Contact

mailing address
1415 doerr rd
quakertown, pa
18951

ARCTIC BLAST 2010

PARENT NAME(required)
CHILD LAST NAME(required)
CHILD FIRST NAME(required)
Email(valid email required)
BIRTHDATE(required)
GRADE(required)
CHURCH ATTENDING
FIRST TIME CAMPER?
YES NO
GENDER
Male Female
ADDRESS(required)
CITY(required)
STATE AND ZIP(required)
MOTHER'S NAME(required)
MOTHER'S PHONE Number(required)
FATHER'S NAME(required)
FATHER'S PHONE (required)
EMERGENCY CONTACT PERSON #1(required)
Emergency Contact #1 Phone Number(required)
EMERGENCY CONTACT PERSON #2(required)
Emergency Contact #2 Phone Number(required)
FOOD ALLERGIES? IF YES, PLEASE LIST.(required)
I understand the risks of outdoor activities and camping life, and consent to the following: I shall not hold the camp responsible of legally liable for losses of personal property or bodily injury; my child may participate in all camp activities; camp photographs/videos in which my child appears may be used in camp publicity, publications, and or promotions.
yes
HOW DID YOU HEAR ABOUT MEN-O-LAN?
SCHOOL FRIEND CHURCH WEBSITE OTHER
Payment Options After form is submitted.
-25.00 will be reflected in Payment Options