Please mail this application to 334 East Kearney, Springfield, MO 65803-3018

Application For Happy Hollow 2011

Early registration is desired

LAST NAME______________________________FIRST__________________________________SEX________DOB____/____/____

ADDRESS________________________________CITY__________________________________STATE______ZIP__________

SCHOOL GRADE (LAST YEAR)____________________________PHONE(_________)_____________________________________

CHURCH PREFERENCE_______________________________________________________________________________MEMBER______

MY HOME CONGREGATION IS___________________________________________________________________________

I HAVE A PARENT WHO IS A STAFF MEMBER__________________________________________

(Check One)

____ I ENCLOSE $90 FOR FULLY PAID, OVERNIGHT SESSION BEFORE MAY 31

____ I ENCLOSE $100 FOR FULLY PAID, OVERNIGHT SESSION AFTER MAY 31

____ I ENCLOSE $50 FOR FULLY PAID, DAYCAMP SESSION BEFORE MAY 31

____ I ENCLOSE $60 FOR FULLY PAID, DAYCAMP SESSION AFTER MAY 31

____ I ENCLOSE $60 FOR GIRLS SESSION 6. $70 AFTER MAY 31

____ I ENCLOSE $60 FOR SESSION 4. $70 AFTER MAY 31

(Check a session)

___1^ST over-night, ___2^ND over-night, ___3^RD day-camp, ___ 4^THover-night, ___ 5^TH day-camp,

___ 6^th over-night, ___ 7^TH girls-session, ____ 8^th over-night

Your medical insurance company____________________policy/group#_________________________

For insurance purposes, all camp staff and their children need to fill out an application. One child admission free per staff parent at same session.

Fees for all night sessions include daily canteen and any craft activities.

Important note to parents or legal guardian

( You must sign this part of the application before it is considered complete)

It is agreed that the camp is released from liability in connection with medical administration except as covered by camp insurance. All medical claims must be filed with the camper’s personal insurance, if insured; then filed on camp hospital insurance for balance or difference. Our medical insurance for campers and counselors covers ONLY what your private insurance does not pay. However, it will not pay any of the deductible of your policy.

(Parents or Guardians signature)

Happy Hollow Bible Camp has my permission to use photographs of my child or children in our Web brochure. ( Must be signed by legal parent or guardian of the child listed on this application )

__________________________________ ______________________

(Parents or Guardians signature) ( Date)

Happy Hollow T-Shirt Order Form

If you want a camp T –shirt in 2011, they are free to registered campers and staff if you fill out the order form below. If you include the form with your registration, shirts will be passed out at your session. Otherwise, it will be mailed to you. No exchanges can be made, so pick your size carefully! Only one free t-shirt allowed per person. We must have a completed order form (staff & campers) in order for you to receive a t-shirt.

Name______________ Phone(___)_______________

CHILDREN’S SIZES: Circle one: M L

ADULT SIZES: Circle one: S M L XL XXL XXXL

(No other sizes available)

FIRST SESSION ATTENDING

CIRCLE ONE

1^ST 2^ND 3^RD 4^TH 5^TH 6^TH 7^TH 8TH

SULLINS BAGGETT BUCKNER MAPLES HEAVIN HATHCOCK HANSEN MCNEESE

(PLEASE COMPLETE MAILING LABEL BELOW)

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

NAME_____________________________________

ADDRESS___________________________________

CITY________________STATE____ZIP__________

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