WCCC Electronic Application – Waynesboro Church of Christ

I am a:

Returning Camper
New Camper

Name *

First

Last

Address *

City *

Zip *

Phone *

Parents Work Phone *

Birthdate *

Grade *

Gender *

Male
Female

Church You Attend

Do you have any physical handicaps? *

Yes
No

If "Yes" to the previous question, please explain: *

Answer "NA" if none

List any medications you must take: *

Answer "NA" if none

List any allergies you have: *

Answer "NA" if none

Do you have health insurance:

Yes
No

Insurance Co.

Answer "NA" if none

Insurance Co. Policy Holder

Answer "NA" if none

Insurance Co. Policy Number

Answer "NA" if none

Insurance Co. Policy Group Number

Answer "NA" if none

Please choose a t-shirt size:

CAMPER DISCLAIMER: I will abide by all camp rules, be a good sportsman, dress according to camp policy and exhibit a good Christian example at all times. I agree to follow the directives of the Wayne County Christian Camp directors and leaders at all times. I understand that failing to comply with the rules of this camp may result in my dismissal from camp and require my parent/guardian to make arrangements for my early departure. *

By checking this box, as a camper you agree to the above Camper disclaimer.

PARENT/GUARDIAN DISCLAIMER: I, the undersigned parent or guardian, hereby consent to my child mentioned in this application, participating in the activities connected with Wayne County Christian Camp at Mid South Youth Camp in Henderson, Tennessee. I certify that my child is able to participate in all activities including sports and other camp related activities (unless indicated in the medical information on this application). I also give Wayne County Christian Camp permission for my child to be transported off the camp property to all camp-related activities. In case of accident or serious illness, Wayne County Christian Camp has my permission to secure the proper medical attention. *

By checking this box, as the Parent/Guardian you agree to the above Parent/Guardian disclaimer.

Wayne County Christian Camp Fee

Price: $ 35.00

**If your child needs a ride to and/or from camp, please call the Waynesboro Church of Christ office at 931-722-5520. The bus will leave Thursday, April 25th at 3:15PM from the church building.