EmailMe Form - 2016 We Are LA! Peace Camp

Name (Legal) *
First Last
Birthdate *
MM / DD / YYYY
Grade *
Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Home Phone *
### - ### - ####
Cell Phone
### - ### - ####
Email
Does the camper have any known allergies?
Yes
No
Please specify
Emergency Contact Information
Please enter the name of the parent or guardian who should be contacted in the case of an emergency.
Name *
First Last
Relationship
Home Phone *
### - ### - ####
Cell Phone
### - ### - ####
Email
Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Questions or Comments
*Payment of $60.00 for each camper can be made to ReconciliAsian in form of cash or check at the camping location, Mountain View Mennonite Church.

*Parents/Guardians will be expected to sign a Medical Consent Form as well as a Parental Consent form also at the on-location registration.