2009 CAMP WORKSHOP REGISTRATION FORM

Full Name _________________________________________________________________________

Parents’ or Legal Guardian’s First Name(s) _________________________________________________

Mailing Address ______________________________________________________________________

City ____________________________________________________ ST ____ Zip ____________

Home Tel ____________________ Cell ____________________ E-mail _____________________

Emergency Contact __________________________ ___________________ _______________

Name Telephone Relationship

Participant Name Camp Name Age Grade M or F Camp Fee Total

_____________________ _______________ _____ _____ _____ $ _______ $ _______

_____________________ _______________ _____ _____ _____ $ _______ $ _______

_____________________ _______________ _____ _____ _____ $ _______ $ _______

_____________________ _______________ _____ _____ _____ $ _______ $ _______

CAMP SCHEDULE AND FEES

Camp Name Grades Dates Fee
High School Camp 9 thru 12 (Heartland) June 29 thru July 4 $210.00
Jr. High 6 thru 8 (KOHOE) July 7 thru July 11 $90.00
Elementary 2 thru 5 (KOHOE) July 12 thru July 14 $50.00
Bus Transportation – from Tensuke Market ($15.00 fee paid by Chicago Family Church) $ N/C

I will travel to the camp by:  Own Car  Chicago Family Church Bus  Other: _______________

CONSENT AND HOLD HARMLESS

I acknowledge that I am participating in an educational workshop organized by HSA-UWC (Family
Federation) and that this activity is being done with my consent and I am aware of the program and
activities involved. I agree to hold HSA-UWC/Family Federation harmless for the safety and wellbeing of
my participation in this workshop and to indemnify HSA-UWC for any and all claims arising there from.

_______________________________ _______________________________ ______________

Signature Printed Name Date

PAYMENT METHOD

 Check (payable to HSA-UWC, Attn: CYM)  VISA  Master Card  Discover (No other cards)
Note: Add 3% of the Camp Fee to the credit card payment amount to cover the bank processing fee.

Credit Card No.  Expiration Date 

Exact Name on Card ______________________________ Signature ________________________

Billing Address _______________________________________________________________________

City ____________________________________________________ ST ____ Zip ____________

PLEASE SUBMIT THIS COMPLETED FORM WITH YOUR PAYMENT, CODE OF

CONDUCT FORM AND MEDICAL AUTHORIZATION FORM.