Elevate–Empower Camp Registration

First Name *

Last Name *

Student's Email (must be unique) *

Gender *

Birthdate *

Street *

City *

Country *

State *

Zip Code *

Mother's Email

Father's email

High School Name

High School Graduation Year *

College Entry Term *

When I go to college I am interested in studying *

Preferred Phone

Mobile Phone *

Home Phone *

Have you personally accepted Jesus Christ as your Savior? *

T-Shirt Size *

Emergency Contact - Name and Phone *

Please list any dietary restrictions, special housing needs, or roommate requests.

Comments

All students must complete and bring their signed medical release form to registration.