Vraj Youth Camp 2018
General Registration

ONLINE CAMPER REGISTRATION FORM
PART I

Please ensure that your information is accurate before continuing to payment.

Important Notes:

  1. Registration must be completed by a Parent or Legal Guardian of the camper.
  2. Registration form is in two parts. Part I is on-line. Part II is a mail-in form.
  3. Each completed application must be mailed in a separate envelope, along with all five required documents. Multiple applications mailed together will result in the cancellation of all applications.
  4. Space is limited and the camper will be admitted after online payment, and upon approval by the Vraj committee.
  5. All correspondence will only be via the parent's email address on this registration form. Please ensure the accuracy of your email address.
  6. Multiple registration for the same camper would invalidate all. Your donation will be fortified.
  7. All Registrations will be voided if dispute filed with paypal, credit card or bank.
Name of Camper
First Name* Middle Name Last Name*
Gender*

Number of year(s) camp attended: year(s).
Date of Birth(MM/DD/YYYY)*
Between 13 to 16 yrs.
           Age:
Camps*
*Camp slot is assigned only after successful payment. The above counts are only current indicators.
 
13-16 yrs
(Jul 14-21, 2018)
Boys: Slots Left: 50
Girls: Slots Left: 42

13-16 yrs
(Jul 21-28, 2018)
Boys: Slots Left: 42
Girls: Slots Left: 50
   
Father's First Name* (no space and title)
Mother's First Name* (no space and title)
Home Address* Street 
City   State   Zip 
Parent's E-mail*
(Camper's email NOT allowed).
Use same email as paypal.
Confirm Parent's Email*
Camper E-mail
Parent's Phone (xxx-xxx-xxxx)* Home*:   Work*:   Cell*:
Camper's T-Shirt Size*
You will not be able to request a different size at the Camp.
Emergency Contact (If parent/guardian cannot be reached) *

Full Name:   Relation
Home Phone (xxx-xxx-xxxx):   Cell Phone (xxx-xxx-xxxx):
Health Insurance Information (If no insurance, enter "NA" in each fields.) *

Health Plan:   ID#:

Subscriber Name:   Group #:
List any medications/special attention that your child may need (write "None" if not applicable)
Medication*
Allergy (Drug or Food)*
Important Note:
Vraj facilities has been used for food preparation with Peanut, Tree Nuts, Soy, Milk and Wheat.
Vraj does not provide quarantined facility or meals to camper with specific dietary requirements.
Does your child have ADHD (Attention Deficit Hyperactivity Disorder) or other related disorder,
which adult volunteers need to be made aware of?*  [  ]
If Yes, Explain:
Parent/Legal Guardian's Full Name for Consent Form*
Relationship*