Address:______________________________________________

City:_________________________________________________

State:______________________ Zip Code:_________________

Home Phone #:________________________________________

Age:_________ Male:___ Female:___

Email Address:________________________________________

Parent/Guardian's Name:________________________________

Their Work Phone #:____________________________________

Home Congregation:____________________________________

Church Address:________________________________________

I have attended the Four States Praise Camp _____ years prior to this year.

I would like to order ____(#) of CDs.

Health Information

This information MUST be completed by the parent or guardian of every student attending!!

Name:________________________________________________

Special Medical Concerns:  (Will be kept completely confidential)

• Allergies:______________________________________________
• Medications:___________________________________________
• Medical Disorders:______________________________________
• Comments:_____________________________________________

Student's Physician's Name:_____________________________________

Physician's Phone #:____________________________________________

I, the parent and/or guardian of the above-named child, give my authorization for emergency medical care if the need arises.

Signature of Parent/Guardian:____________________________________

Alternate Contact:______________________________________________

Alternate Phone:_______________________________________________

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Send this form, along with your $50 deposit (total fee is $160, balance due on arrival), to:

This application must be received no later than June 3, 2007.