Breaker Rock Beach Kids Camp
If you or your child would like to participate in this event as a Participant, please complete the following form.

(If you are under 18, please have your parent or guardian complete the form.)
Personal Information
*Participant's First Name:
*Participant's Last Name:
*Gender:
*Grade Completed:
(LAST school year; 2023-2024)
*School:
(NEXT school year; 2024-2025)
*Birthday:
(MM/DD/YYYY)
*Allergies/Medical Info:
(i.e. Peanuts; Uses Inhaler etc.)
*Parent/Guardian Name:
*Cell Phone:
(555-555-5555)
*Email:
*Address:
*City:
*State:
*Zip:
*Emergency Contact:
(Must be reachable at ALL TIMES)
*Emergency Contact CELL:
(555-555-5555)
Alternate Pickup Person 1:
(OTHER THAN adults listed above)
Pickup 1 CELL:
(555-555-5555)
Alternate Pickup Person 2:
(OTHER THAN adults listed above)
Pickup 2 CELL:
(555-555-5555)
*Does your family have a church?:
*What church do you attend?:
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