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Camp Application

Complete the below On-Line Camp Application
or download the Camp Application:
Part 1 of 2
Part 2 of 2
and mail the completed Application to the address below.

CAMP GUIDELINES: Read Summer Camp Guidelines. What to bring and what not to bring and our policies.

IMPORTANT: Please download the Camp Pioneer Medication Consent Form and bring it with you the first day of camp.

A $25 non-refundable deposit is required to reserve your spot at Camp 2010.
Payments can be made by clicking on the Donate button below
or you can mail your $25 non-refundable deposit to:
Pioneer Ministries
Post Office Box 6182
Jackson, MS 39288-6182



Camp Pioneer 2010 On-Line Camp Application

This is a Duplicate Application or Re-Do?  Yes

Camper's Name

Camp Week (select the week you will be attending)

Address

City State Zip

Sex  Female Male

Birthdate (MM/DD/YY) Age at Camp Time

Parent's Name

Parent's Email Address

Parent's Phone

Other Emergency Contact Name

Emergency Phone

Home Church

Pastor's Name

Phone Number

I give permission for pictures of my child and letters written by my child to be used for publicity.  Yes No

Health Survey

Describe any Emotional or Health Problems

Describe any Allergies or Allergic Reactions

Approximate Date of Last Tetanus Shot

Activity Restrictions

Insurance Provider

Insurance Policy Number

Parent/Camper Commitment

I (Camper) agree to abide by the rules of Camp Pioneer. We understand that improper behavior and/or violation of any rules may result in early termination of the camp week with no refunds.

Parent's Name

Camper's Name

Please check over the above application before clicking Send. If you have any questions please call (601) 939-3659.