Youth Camp 2021 Registration

Genesis Youth Camp is June 28 – July 2 at Logan Valley Christian Retreat in Ellington, MO.  You can view the Logan Valley website here:  https://www.loganvalley.org/

A $50 deposit is required to register, although online payment is optional.  A complete health/travel release form is required – see Travis for copies or print the form below.  Questions should be sent to [email protected].

Youth Camp 2021 Registration Form

Camper Name *

First

Last

Camper Age Group (in the fall) *6-8 grade9-10 grade11-12 grade

Indicate the camper's school grade in Fall 2021.

Does the camper have any known allergies? *

• Yes
• No

If Yes for allergies, indicate specific allergy:

Has the camper attended Genesis Youth Camp before? *

• Yes
• No

Emergency Contact Information

Please enter the name of the parent or guardian who should be contacted in the case of an emergency.

Relationship *

• Parent
• Sibling
• Relative
• Friend

Name *

First

Last

Email *

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Questions or Comments

Stripe Credit Card

Credit Card Payment is Optional

Checkbox Items

• $50 Deposit (due 6/16)
• $250 Full Amount (due 6/28)

Submit

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