APPLICATION

EPISCOPAL CHURCH CAMP OF ILLINOIS 2004

Sunday, July 4 to Saturday, July 10, 2004

All applications must be postmarked by JUNE 1, 2004

To ensure a confirmed registration for 2004 Episcopal Church Camp, please send this completed application with a

$50 registration deposit or parish scholarship made payable to Episcopal Church Camp of Illinois to the registrar:

Annette Carr

3120 W. Chain of Rocks Rd. #274

Granite City, IL. 62040

Camp Fees

$190 for the first member of a family

 $170 for the second member of a family

$150 for all additional family members

(**Note: EARLY BIRD DISCOUNT:  if full fees are received by April 15, 2004, please deduct $10 per camper)

All camp fee payments must be received by the registrar no later than June 1, 2004

Camper/Participant ______________________________  Parent’s e-mail_____________________

Address_______________________________________________ Phone (      ) ________________

                                      Street

              _______________________________________________

                                 City                                    State                                     Zip

Birth date (MM/DD/YY) ______________ Age _____ Sex ____ Grade Completed, June 2003_____

Home Parish ______________________________________________________________________

                                                 Parish Name                                                         City                                                    Diocese

Please list any siblings that the camper will have at camp (First and Last Name). ___________________________________________

_____________________________________________________________________________________________________________

Special requests: Include here buddy requests, special needs (please be specific), or vegetarian diet requests. _________________________________________________________________________________________________

_________________________________________________________________________________________________

T-shirt size (all are adult sizes) Sm____   Med____   L ____   X-L ____  XX-Lg____   XXX-Lg____

Please note: No applications will be processed without complete information for parents and two emergency contacts (back of application) and the Camp Health Form.  Applicant is not registered if application is received without this information.

After your application is processed, you should receive confirmation of your registration within two to three weeks. Please be patient.

EMERGENCY INFORMATION:

Camper’s Name__________________________________________________________

Parent(s) Name ________________________________________________

Home phone ___________________________Work phone ____________________________

                                    Required

Emergency Contacts:

In case of emergency, please contact (please provide at least two):

Name ________________________ ______________Relationship to Camper ______________

Phone ___________________________Work phone __________________________________

Name ______________________________________Relationship to Camper ______________

Phone ___________________________ Work phone__________________________________

The health form is also required by East Bay Camp; it will remain in the health center during camp.