Youth Winter Registration Form

There are three ways to register for winter retreat:

  • Register here online.
  • Call Delta at (315) 336-7210
  • Print out this form and mail or fax it to the office Click Here

Camper's Name:

Address:

City and State:     Zip Code:

Home Phone:

Email:

Gender:   Male      Female

Date of Birth:

Grade:

Attending as a Chaperone:    Yes     No

Name of Parent / Guardian: 

Work Phone:

Attended Camp Before At Delta Lake:   Yes      No

Are you planning on going Skiing? (Additional Charge)   Yes     No

Roommate Request (s)  - Maximum of 2:

         

Church the Camper Attends:

Weekend Attending:

Medical Information:

Guest Name:

Parent/Guardian's Name (s): 

Insurance Name & Address:

 

Policy Number:

Group Number:

Your personal or family insurance would apply to all claims while at Delta Lake.  However, the camp does provide Excess Medical Expense coverage.

Allergic reactions to any medication:

 

Emergency Phone Numbers:

Home:

Work:

I do give my permission for the above listed person to participate in the program of the Delta Lake Bible Conference Center, and I do give permission to the camp's nurses, registered first-aid persons, local doctors and/or hospitals to administer proper medical assistance to the above named person, should the need arise.    Typed Signature:   

                        Relationship:          Date:

Note: Registration is not complete until the registration fee is received.

Payment Options: