Antioch Baptist Church​

EST  1833​

6670 Old US 421, Lillington NC 27546         

910-893-5986

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Camp Change Registration
Please read the "Camper Release Form" and then complete the form below.

Camper Release Form
Camper Mailing Address (If different from Physical)
Camper Age and Just Grade Completed
Parent/Caregiver Number
Parent/Caregiver Name
Emergency Contact Name
Emergency Contact Number
Do we have permission to take photos/videos of your child for the purposes of the camp electives and for promotional materials?
By typing my name below, I acknowledge that I have downloaded and read the "Camper Release Form attached and agree to the terms and conditions therein.
Camper Physical Address
Family Doctor Name
Family Doctor Phone Number and Address
Insurance/ Medicare Policy Number
When was the last time your child had a tetanus injection?
Date
Allergies/Health Concerns/Special Needs
Camper Name
Submit