*This form must be submitted by May 16, 2014

Name: Home Phone:
Gender: MaleFemale Cell Phone:
Date of Birth: Email:
School: Year in School:
Are you a certified lifeguard? (not required):

Are you certified in first-aid? (not required):
In what year did you attend Loaves and Fishes as a camper?
Parent or Guardian Name(s):
In what hobbies, sports, work, or activities are you involved?
Parent or Guardian(s) Cell #:
Parent or Guardian(s) Email Address:
Medical History: Do you have any allergies or medical conditions that we should know about?
Dietary: Are there any foods you are allergic to or otherwise absolutely cannot eat?