Camper Registration Test

  • Date Format: MM slash DD slash YYYY
  • Daily Care Information

  • Medical Information

  • Special Note


    Be sure that an adequate number of medications are sent in the original prescription containers, with the camper’s name and instructions on the bottle. Be sure that the dosage on this application and on the bottles are the same. It is helpful if we know when you give the medicine; for example, mealtimes, bedtime, etc. This information is very important so we can adapt to special needs when we are aware of them. Medications are to be put in a separate bag, marked “Nurse.” Please do not give campers their own bottles of aspirin, cough syrup, etc.
  • Insurance Information

  • Date Format: MM slash DD slash YYYY
  • Permission:

    I give my permission for any medical treatment necessary for the camper’s health and well-being. *NOTE: Typing your name will be treated as your signature and is binding!
  • Date Format: MM slash DD slash YYYY
  • Insurance Cards

    NOTE: Please provide copy of all insurance/Medicaid/Medicare ID card(s)
  • Permissions

  • *NOTE: Typing your name will be treated as your signature and is binding!
  • Registration Information


    COST: $350 ($300 + $50 Deposit) due July 1, 2020. $50.00 deposit and a completed application form is required to reserve camper’s spot!

    Mail completed application & balance of fee by July 1, 2020 to: Camp Jubilee PO Box 81 Reidsville, NC 27323

    Contact Information

    For further information or questions contact:

    Candice Hughes, Program Director [email protected]

    Cecil Cottrell, MJM Executive Director [email protected]

    Scholarship assistance is the responsibility of Camper Families. MJM recommends First in Families of North Carolina (http://fifnc.org) as one option. Once all scholarship opportunities have been exhausted unsuccessfully, please contact Cecil Cottrell.