HOLSTON PRESBYTERY CAMP SUMMER CAMP REGISTRATION
(please use black ink)

CAMPER NAME___________________________________________________     Male______    Female_______
Address ___________________________________  City_______________________    ST______      Zip_______
Age as of camp arrival_________        Date of Birth_____/_____/_____

Number of years attended as camper at Holston Camp?_______

All registered campers will receive a FREE Camp Shirt
Circle size:        Youth   6-8     10-12      14-16              Adult   S    M    L    XL

(Father)    Name__________________________  Work (_____)_____-________     Home(_____)_____-_________
(Mother)   Name__________________________  Work (_____)_____-________     Home(_____)_____-_________
Email Contact ___________________________________________
Emergency Contact ______________________________ Relation______________ Phone(_____)_____-________

Church attending_________________________________ Denomination_____________________________
Camper must be a member of a Holston Presbytery, PCUSA Church to qualify for reduced camp fees

Camp Session:
1st choice:         Code____________________   Dates:__________________    Cost:________________
2nd choice:       Code____________________   Dates:__________________    Cost:________________
My chosen friend (friend must also choose you)_____________________________________________

$50 Non-Refundable Registration fee required per person (child or adult)

Check amount enclosed $____________    All scholarship money MUST be handled between the church and the camper. Make check payable to: HPC & RC

Visa/MasterCard Number_________-_________-________-________        Expiration Date_____/_____/_____
Visa/MasterCard Holder Name_______________________________________________

Please charge my credit card_________________________ amount. (Minimum of $100 registration fee)
Balance due prior to arrival at camp
Mail to: Holston Presbytery Camp & Retreat Center
               PO Box 428
               Banner Elk, NC 28604
              (828) 898-6611

I give permission for my child to attend summer camp and participate in all phases of camp activities including trips as related to the camp program. I understand that Holston Presbytery Camp may use photographs and/or video tapes of my child for public relations. I understand that the camp cannot be responsible for lost valuables.

Signature_________________________________________________    Date___________________________