Registration

GREATER VISION

11901 Eastfield Road Huntersville, NC 28078

Cornerstone Charlotte

Greater Vision Academy Registration Form

11901 Eastfield Road, Huntersville, NC 28078 Phone: 704-947-8228 Fax: 704-947-8992 Registration Fee: $25.00 Non Refundable

Is the T-Shirt Size Children or Adult?

HOW DID YOU HEAR ABOUT US?

Name: Student Name

Email

Parent Name

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Parent Employer

Employer Phone Number

Mailing Address

Required

Home Phone

Required

Mobile Phone

Required

Date of Birth

Required

Free/Reduced Lunch in CMS

Required

T-Shirt Size

Required

List person(s) and contact information authorized to pick up your camper.

Required

Social Media

Word of Mouth

Advertising

Children

Adult

Required

Week 1 June 11 - 15

Week 6 July 23 - 27

Week 2 June 18 - 22

Week 7 July 30 – August 3

Week 3 June 25 - 29

Week 8 August 6 - 10

Week 4 July 9 - 13

Week 9 August 13 - 17

Week 5 July 16 - 20

List Emergency Contact Information

Required

Is this camper covered by insurance?

Required

Insurance Subscriber's Name

Required

Address

Required

List of Allergies

Required

Subscriber's Name

Required

Policy Number

Required

Policy Number

Required

List of Restrictions/Medical Issues

Required

Group Number

Required

Camper's Relationship to Subscriber

Required

Week/Weeks that your child will be attending camp. (Check each week that applies).

Medical Information (Please email a copy of your insurance card front & back).