Online Registration

*Required Fields

Select Week *

Camper Information

Camper Name *

Birthdate *

Age *

(Junior campers must be at least 8 at time of camp. Teen campers must be at least 12 at time of camp)

Gender *

Camper Address *

Camper City *

Camper State *

Camper Zip *

Email *

Camper Home Phone *

Must include area code (ex. 717-545-2599)

Camper Cell Phone *

Must include area code (ex. 717-545-2599)

My Room Request

(One choice, within 2 years in age—first and last name, please!)

Church Name

T-shirt (included) *

select size from drop-down list

Parent/Guardian Information

Parent/Guardian name *

Parent/Guardian Relationship *

Parent/Guardian Email

if different from camper

Parent/Guardian Emergency Contact: Primary *

Must include area code (ex. 717-545-2599)

Parent/Guardian Emergency Contact: Secondary

Must include area code (ex. 717-545-2599)

Medical Information

Camper Physician *

Physician Phone *

Must include area code (ex. 717-545-2599)

Tetanus current? *

Yes

Campers must be immunized against: mumps, measles, whooping cough, polio, diphtheria, rubella, tetanus

Medications taken regularly

Reasons for taking medication

Signature Required

(typing your name below will qualify as your digital signature)

General Information

Click Here & Read

Parent/Guardian Signatures

I have read the general information, and I agree to support Mt. Lou San in their dress and conduct regulations for my child. I also give permission to use photos and video including the camper in camp publicity. In case of medical emergency, I understand that every effort will be made to contact parents or guardian of campers. In the event I cannot be reached, I hereby give permission to the physician selected by the camp director to hospitalize and secure proper treatment for and order injection and anesthesia or surgery for my child. I agree to release any records necessary for treatment, referral or billing purposes.

Signature of parent/guardian *

Pay Online

After submitting this registration you will be taken to our online payment page. Please pay your $50 deposit, $240 total payment or other by: 1) clicking the 'Give Now' button and 2) selecting 'Camper Payment' from the Categories and Funds drop down list.

SPECIAL NOTE FOR THOSE REGISTERING MULTIPLE CAMPERS:
For anyone registering multiple campers, please make ONE PAYMENT for the grand total of $50 deposits or full $240 payments (our merchant account does not allow identical payments from the same card on the same day).

Your Payment *

I will pay the $50 Deposit Online (nonrefundable)

I will pay the Total Amount of $240 Online

Other (multiple campers, scholarship, etc.)