Mississippi Valley Christian Service Camp
Registration Card (Back)

Registration Card for_____________________________________________________________
(Name)

Camp Regulations will apply to everyone on camp grounds. Integrity and Christian conduct must prevail at all times. The Camp Deans and Managers reserve the right to dismiss anyone who does not obey camp policies and regulations.

All campers leaving prior to end of camp must sign out with the Dean, and report back upon arrival.

Audio/Visual Release
I give Mississippi Valley Christian Service Camp permission to record and use still photographs or audio and video recording of myself/my son/my daughter

________________________________________________(name of camper)
I agree and understand that such material may be used in an informational and educational manner for the purpose of promoting Mississippi Valley Christian Service Camp. I understand that any images of myself, my son/daughter that may be used for such purposes will be presented in a manner such that there will be no infringement of my/his/her individual privacy and that the utmost respect will be shown in the use and presentation of such material.
Signature of parent or guardian

_________________________________________________Date_________

To preregister (recommended) please mail this form, along with your payment, to 24201 State Route 100, Pittsfield, IL 62363. If you are a member of one of the area Christian Churches, there are scholarships available to you -- see your minister. Scholarships for non-members are also available: call (217)723-4337

FOR OFFICE USE ONLY
___________Amount Paid _____________Date Received

____________________________Church to Pay (attach signed voucher from church)