Kids Camp Registration

Child's Name

Child's Age

Date of Birth

Parent's Full Names

This address will receive a confirmation email

Phone/Cell Phone

Address

Home Church

What school does your child attend?

One friend in same grade your child would like to be with. We cannot move a child up a grade to be with a friend but the friend can move down a grade.

Allergies, Medical Conditions, or Special Needs

Emergency Contact #

Relationship to Child

Medical Release: I hereby authorize the treatment of the minors registered on this form for activities at 4Cs by a qualified and licensed medical doctor in the event of a medical emergency which, in the opinion of the attending physician, may endanger his/her life, cause disfigurement, physical impairment, or undue discomfort if delayed, while said child is participating in a church program. Initial box below.

Insurance Release: I realize Christ community covenant Church insurance begins where the individual's health and accident policy terminates. It is only valid when all other insurance has been extended to its limits. Initial box below.

Personal Belonging Release: I realize that Christ community Covenant Church is not responsible for personal belongings. Initial box below.

Discipline Release: If in the event of repeated misconduct, I authorize the staff to send my student(s) home at my expense. Initial box below.

Video/Photography Release: I hereby grant 4Cs and its representatives’ permission to use for this and any event until rescinded by me, without compensation or restriction, photographs and videotape images in which the participant appears, in any manner whatsoever such as, but not, limited to: publication, display, advertising, slide shows, etc. Initial box below.

General Release: The undersigned or a member of the immediate family of the undersigned realizes that the participant(s) may incur personal injury or bodily damage while participating in such activities, and acknowledges that Christ community Covenant Church, its officers and its directors, and its employees, its agents, and any parties volunteering on behalf of Christ Community Covenant Church shall be held harmless from all actions, claims, costs, expenses or damages of any kind, growing out of or related to any activity of Christ Community Covenant Church. The undersigned or a member of the immediate family of the undersigned further acknowledges this is a full and complete release for all injuries and damages which the participant(s) may sustain as a result of participation in any church activity. I, being the legal guardian of the minors registered on this form for activities at 4Cs, give my permission for the minors registered on this form for activities at 4Cs to participate in activities at 4Cs sponsored by Christ Community Covenant Church. The parties agree that this Agreement may be executed with electronic signatures. By typing your name below, each party confirms that they are intending to be legally bound by this Agreement.

Date:

Insurance Company or Group and Policy Number

Payment $50.00

Dates Attending

T-Shirt Size

Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X-Large

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Kids Camp Registration

Description

Please Fix the Following