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CAMP PORTER SPRING BREAK REGISTRATION
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PARENT OR GUARDIAN'S FULL NAME
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HOME PHONE
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Email
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Address Line 1
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Mayotte
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Monaco
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Morocco
Mozambique
Myanmar
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Nauru
Nepal
Netherlands
New Caledonia
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Niger
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Niue
Norfolk Island
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Northern Mariana Islands
Norway
Oman
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Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
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Tonga
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Tunisia
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Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
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United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
CHILD'S NAME
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CHILD'S BIRTH DATE
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AGE
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GRADE
*
SCHOOL
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Does your child have any allergies (seasonal, food, etc.)?
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Yes
No
Does your child have any medical issues? (Explain Below)
List preferred Hospital or Medical facility for this child in case of medical emergency:
If answered "Yes" above, please list allergy here
Other information needed to ensure the proper care of your child:
MOTHER'S NAME
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FATHER'S NAME
MAIDEN NAME (SECURITY PURPOSES)
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Address
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Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
MEMBER OF GCT?
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Yes
No
HOME PHONE
*
WHERE EMPLOYED
*
BUSINESS ADDRESS
BUSINESS PHONE
BUSINESS EMAIL ADDRESS
*
FATHER'S NAME
*
Address
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
--- Select country ---
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia (Plurinational State of)
Bonaire, Saint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo (Democratic Republic of the)
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Kingdom of)
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran (Islamic Republic of)
Iraq
Ireland (Republic of)
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea (Democratic People's Republic of)
Korea (Republic of)
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia (Federated States of)
Moldova (Republic of)
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia (Republic of)
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine (State of)
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russian Federation
Rwanda
Réunion
Saint Barthélemy
Saint Helena, Ascension and Tristan da Cunha
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten (Dutch part)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Republic of China
Tajikistan
Tanzania (United Republic of)
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkmenistan
Turks and Caicos Islands
Tuvalu
Türkiye
Uganda
Ukraine
United Arab Emirates
United Kingdom of Great Britain and Northern Ireland
United States Minor Outlying Islands
United States of America
Uruguay
Uzbekistan
Vanuatu
Vatican City State
Venezuela (Bolivarian Republic of)
Vietnam
Virgin Islands (British)
Virgin Islands (U.S.)
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
Country
MEMBER OF GCT?
Yes
No
HOME PHONE
*
WHERE EMPLOYED
BUSINESS ADDRESS
BUSINESS PHONE
BUSINESS EMAIL ADDRESS
ARE PARENTS DIVORCED OR SEPERATED?
CHILD RESIDES WITH:
*
FATHER
MOTHER
BOTH
OTHER
ARE PARENTS DIVORCED OR SEPERATED?
DIVORCED
SEPERATED
WHICH PARENT HAS CUSTODY OF CHILD?
*
Registration Fee for 1st Child
*
Payment: $100
ADDITIONAL CHILDREN
ARE YOU REGISTERING ANY ADDITIONAL CHILDREN?
*
Yes
No
HOW MANY ADDITIONAL CHILDREN ARE YOU REGISTERING?
*
CHOOSE HOW MANY ADDITIONAL CHILDREN
1 - $100.00
2 - $200.00
3 - $300.00
4 - $400.00
Child's Name (2nd Child)
*
First
Last
Age
*
Child's Birthdate
*
Grade
*
School
*
Food Allergy?
Indicate the allergy(s) that this child has, if there are any.
Does your child have any medical issues? (Explain Below)
Preferred Medical Facility in case of emergency for this child:
Child's Name (3rd Child)
*
First
Last
Age
*
Child's Birthdate
*
Grade
*
School
*
Child Allergy?
Indicate the allergy(s) that this child has, if there are any.
Does your child have any medical issues? (Explain Below)
Preferred Medical Facility in case of emergency for this child:
Child's Name (4th Child)
*
First
Last
Age
*
Child's Birthdate
*
Grade
*
School
*
Child Allergy?
Indicate the allergy(s) that this child has, if there are any.
Does your child have any medical issues? (Explain Below)
Preferred Medical Facility in case of emergency for this child:
Child's Name (5th Child)
*
First
Last
Age
*
Child's Birthdate
*
Grade
*
School
*
Child Allergy?
Indicate the allergy(s) that this child has, if there are any.
Does your child have any medical issues? (Explain Below)
Preferred Medical Facility in case of emergency for this child:
NAMES(S) OF PERSON(S) OTHER THAN PARENT(S) AUTHORIZED TO ACT FOR PARENT IN CASE OF EMERGENCY:
NAME
HOME PHONE
RELATIONSHIP
WORK PHONE
NAME
HOME PHONE
RELATIONSHIP
WORK PHONE
NAME
HOME PHONE
RELATIONSHIP
WORK PHONE
Total
*
$0.00
Terms and Conditions
*
I understand that those supervising camp activities will exercise a reasonable degree of care. Therefore, I release the director, staff, Bishop Brandon B. Porter, Greater Community Temple, Greater Community Learning Academy and the camp from all liability, and waive any claim against them for any harm or injury which may be sustained by my child while attending Camp Porter. Furthermore, I assume total responsibility for my child’s conduct during his/her attendance at Camp Porter or related trips and activities.
“I hereby consent to release for possible publication of my child’s name and/or photos and video images taken by any authorized Camp Porter representative or employee. This may include television, newspaper, magazine, and/or social media websites."
*
Yes, I authorize
No, I do not authorize
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