registration form for CHWC

Catholic Heart Work Camp Mission Trip
North Haledon, NJ
JULY 17-22, 2022

Student Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

City REQUIRED Please fill out this field. Please enter valid data.

State REQUIRED Please fill out this field.

Zip REQUIRED Please fill out this field. Please enter a zip code.

Email REQUIRED Please fill out this field. Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Gender Female Male

Birthdate REQUIRED Please fill out this field. Please enter a date.

Current Grade REQUIRED Please fill out this field.

Shirt Size REQUIRED X Small Small Medium Large XX Large XXX Large Please fill out this field.

Parent's Information

First Name REQUIRED Please fill out this field. Please enter valid data.

Last Name REQUIRED Please fill out this field. Please enter valid data.

Email REQUIRED Please fill out this field. Please enter an email address.

Phone Number REQUIRED Please fill out this field. Please enter a phone number.

Health Information

Health Insurance Company REQUIRED Please fill out this field. Please enter valid data.

Health Insurance Policy Number REQUIRED Please fill out this field. Please enter valid data.

Known Health Issues REQUIRED Please fill out this field.

Will you be 18 or older by July 17, 2022? REQUIRED Please fill out this field.

Allergies and any medication you will be taking during the trip REQUIRED Please fill out this field.

Emergency Contact Information - Name, relationship, phone number REQUIRED Please fill out this field.

Comments

Payment Information

The total price for the Mission Trip is $600.
A Registration Deposit of $250 IS REQUIRED!
The Balance of the trip will be $350 and there are 2 payment options below: