Junior High Registration - Calvary Chapel of Philadelphia

How many kids are you registering from your household(Required)

Student Information

Student Name(Required)

First Last

School(Required)

Grade(Required)

Please enter a number from 6 to 8.

Home Church(Required)

Date of Birth(Required)

I would like to be placed in a room with:

(one name only) We will try to accommodate

2nd Student Information

Student Name

First Last

School

Grade

Please enter a number from 6 to 8.

Home Church

Date of Birth

I would like to be placed in a room with:

(one name only) We will try to accommodate

3rd Student Information

Student Name

First Last

School

Grade

Please enter a number from 6 to 8.

Home Church

Date of Birth

I would like to be placed in a room with:

(one name only) We will try to accommodate

Medical Release

Parent/Guardian(Required)

First Last

Parent/Guardian Email(Required)

Parent/Guardian Phone Number(Required)

Parent/Guardian 2nd Phone Number(Required)

Please list any allergies, required medications, pre-existing medical conditions, or indicate NONE

If needed, may we administer which of the following:(Required)

Tylenol

Advil

Aspirin

None of the above

Health Insurance Co.

Policy Number

Upload a photo of your insurance card

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 100 MB.

not required, but is helpful. (If registering multiple students, please upload each of their insurance cards)

2nd Student Medical Release

Please list any allergies, required medications, pre-existing medical conditions, or indicate NONE

If needed, may we administer which of the following:

Tylenol

Advil

Aspirin

None of the above

Health Insurance Co.

Policy Number

3rd Student Medical Release

Please list any allergies, required medications, pre-existing medical conditions, or indicate NONE

If needed, may we administer which of the following:

Tylenol

Advil

Aspirin

None of the above

Health Insurance Co.

Policy Number

Parent/Guardian & Student Contract

Parent/Guardian Signature(Required)

Student Signature(Required)

2nd Student Signature

3rd Student Signature

Payment

The registration fee is $200 per person. If you need to change the quantity of attendees after you have registered, you can do so by calling the church office at 215-969-1520.

Total

Credit Card(Required)

American Express

Discover

MasterCard

Visa

Card Number

Expiration Date

Security Code Cardholder Name

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

2025 Junior High Retreat

2025 Junior High Retreat

Student Information

2nd Student Information

3rd Student Information

Medical Release

2nd Student Medical Release

3rd Student Medical Release

Parent/Guardian & Student Contract

Payment