Attendees

Attendee {binding ItemNumber}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Birth Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Health Insurance

The camp insurance is an accident policy only, not a medical illness policy, and is a supplemental policy only. It will pay whatever the attendee’s insurance does not cover (deductible) up to the limit of the policy. If medical care is needed, it will be billed to the parent or guardian, such bills being sent to your home address are to be paid directly to the medical care facility.

Health Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Policy Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Emergency Contact

Emergency Contact Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Relationship to Attendee(s) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Contact's Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Your Church

Church Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Pastor's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Church Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Payment Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Payment Choice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{ binding displayValue, mode=oneTime }

Registration Fee {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Early Payment Discount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Applies only when paying by Monday, November 2.

PARENT’S CERTIFICATION FOR ALL MINORS: In case of an emergency, every attempt will be made to contact a parent/guardian. If parent/guardian cannot be reached, I give permission to the medical personnel selected by the camp to hospitalize and/or secure any proper treatment necessary for my child.

My son/daughter is able and willing to participate in the retreat and has my consent to register for the Raccoon River Bible Camp. I also give permission for any pictures or videos taken of my child to be used for camp promotional purposes.

Parent/Guardian Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{~ Payment_Block_Label}

{binding Group}
{binding Name} - {binding Description}	{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}	{binding displayValue}
{binding Name}:	{binding displayValue}	---

{{ Cognito.resources['payment-amount-due'] + ":" }} {binding displayValue}

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}

{{ Cognito.resources['order-date-label'] }}: {binding displayValue}

{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}

{binding Group}
{binding Name} - {binding Description}	{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}	{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:	({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:	{binding displayValue}

The email has been sent.

Your progress has been saved.

Copy your form link:

Email me my link:

{ binding firstError.message }

{{ Cognito.resources['order-number-label'] }}: {binding displayValue}

{{ Cognito.resources['order-date-label'] }}: {binding displayValue}

{{ Cognito.resources['order-method-label'] }}: {binding MethodReference}

{binding Group}
{binding Name} - {binding Description}	{binding displayValue}
{{ Cognito.resources['payment-subtotal'] + ":" }}	{binding displayValue}
{{ Cognito.resources['order-total-label'] }}: {binding displayValue}
{{ Cognito.resources['order-amount-paid'] }}:	({binding displayValue})
{{ Cognito.resources['order-balance-due-label'] }}:	{binding displayValue}

Attendees

Attendee {binding ItemNumber}

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Birth Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Age {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Gender {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Health Insurance

Health Insurance Company {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Policy Number {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Emergency Contact

Emergency Contact Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Relationship to Attendee(s) {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Contact's Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Your Church

Church Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Pastor's Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Church Address {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Payment Information

Name {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Email {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Phone {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Payment Choice {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Registration Fee {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Early Payment Discount {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Parent/Guardian Signature {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

Date {{ Cognito.resources["required-asterisk"] }} , { binding firstError.message }

{binding displayValue}

Attendees

Attendee {binding ItemNumber}

Health Insurance

Emergency Contact

Your Church

Payment Information

{~ Payment_Block_Label}

{{ Cognito.resources['order-transaction-details-header'] }}

Your progress has been saved.

{{ Cognito.resources['order-transaction-details-header'] }}

Attendees

Attendee {binding ItemNumber}

Health Insurance

Emergency Contact

Your Church

Payment Information