Camper Name *

First Name

Last Name

Phone

(###)

###

####

Date of Birth

MM

DD

YYYY

Gender

Male

Female

What days do you plan to attend?

Day 1 - Monday

Day 2 - Tuesday

Day 3 - Wednesday

Day 4 - Thursday

For which nights do you need lodging?

Day 1 - Monday night

Day 2 - Tuesday night

Day 3 - Wednesday night

Day 4 - Thursday night

I understand the possible risks and dangers in various convention/camp activities and do give my permission for the above named to engage in all camp activities. I do hereby release Victory Chapel Independent Holiness Church as well as the staff of Sunnyside Youth & Family Retreat from all claims, demands, actions or causes of actions sustained during the period covered by this release whether such injury occurs on or off church property.

Yes, I understand and agree to these terms

Parent/ Guardian Name

First Name

Last Name