Registration  for Camp Patmos Youth Camps
camper's name
gender
father's full name
mother's full name
home phone
cell or work phone
mailing address: number/street
city
state
zip

 

 
camper's e-mail
camper's date of birth
grade entering in the fall
t-shirt size (if you want to pre-order)
cost: $10.00 and will await your arrival at registration.
church name & city
(if attending with a group)
cabin mate request
how did you hear about Patmos?

medical
family doctor name
family doctor phone #
insurance company
policy number
cardholder name
allergies

please list any medical concerns

or behavioral conditions for your child:

note: medications must be in original containers and must be accompanied with a completed medication form (sent out with your confirmation)

week attending
junior (entering 4-6th grade) $295
optional programs (+ $65)
junior high (entering 7-9th grade) $295
optional programs (+ $65)
senior high (entering 9-12th grade) $295
optional programs (+ $65)

I certify the above-named camper has my permission to take a full, active part in the program at Camp Patmos. I further authorize Camp Patmos to administer necessary medical treatment in case of an accident or illness which occurs while a registered camper. I also realize that my campers' picture or testimony may be used in the promotion of the camp, and my child may receive e-mail from Camp Patmos.

by a parent or legal guardian typing your full name in this box
you are agreeing to the above statement:
notes:
 

We accept Credit cards through Paypal our online payment processing.
payment options:  
Payment amount and information will be collected on the next screens.