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WAVE Camp (Yorktown) - Elementary School on Monday, July 12, 2021 @ 9:00 AM

These products are for all WAVE camps.

Please fill out the additional registration information below. Thank you!

This section is about the child or student who is participating at or with Coastal Community Church.:
*What grade will your student be in the Fall of 2021?:
*T-Shirt Size:
*Primary Church Campus:
The following fields relate to the Parent or Legal Guardian (who will be the emergency Contact unless otherwise noted):
*Best Phone Number:
Alternate Phone Number:
Work Phone Number:
If you would like to have someone other than the Parents or Legal Guardians as the Emergency Contact please list them below.:
Emergency Contact Name:
Emergency Contact Phone:
Emergency Contact Relationship:
In the event we cannot reach the Emergency Contact who can we call?:
*Name of Alternate:
*Phone # of Alternate:
*Relation to family:
Please provide information about insurance and any medical issues we should be aware of.:
*Do you carry family medical/hospital insurance?:
If so, please indiacte carrier:
Policy #:
Name of Family Physician:
Physician's Phone #:
Name of Dentist/Orthodontist:
Dental Phone #:
Please provide information regarding any of these health issues. | Asthma | Emotional Disorder | Physical Handicap | Bleeding/Clotting Disorder | Nervous Disorder | Hay Fever | Drug/Allergies | Epilepsy | Insect Stings Diabetes | Seiz:
Health Issues - Specific Detail:
List Any Activity Restrictions:
List surgeries or serious injuries and dates:
Chronic illness, medical conditions or allergies:
Current medication (send with instruction):
Date of last tetanus shot - ex. 01/01/1980:
By typing my first and last name in this box I am signifying that I am the parent or guardian for the child listed above and have the authority to enter into this agreement on their behalf.:
*First & Last Name:
If you are a Coastal Member please use the promo code- Member -for $25 off registration. 
If you are registering more than one child, please use the promo code- Sibling -to get $25 off each sibling. 
Please only use one promo code per child.