PRO243: Athletic & Academic Camp

Student Name

First NameLast Name

Student Birthday

Date

Student Completed Grade

Camp Selection

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Allergies

T-Shirt Size

Parent /Guardian

First NameLast Name

Relation to Student

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Emergency Contact

First NameLast Name

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Alt Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relation to Student

Informed Concent & Acknowledgment

I hereby grant my approval for my child’s participation in any and all activities prepared by Endeavor Church during the selected camp. In exchange for the acceptance of said child’s candidacy by Endeavor Church, I assume all risk and hazards incidental to the conduct of activities, and release, absolve and hold harmless Endeavor Church and all its respective officers, agents and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case injury to said child, I hereby waive all claims against Endeavor Church, including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and if applicable, owners and lessors of premises used to conduct the event. There is a risk being injured that is inherent in all sports activities and I hereby acknowledge those risks.

Please sign if you have read and agree to the above

Medical Release & Authorization

As Parent and/or Guardian of the named student, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named student. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after reasonable effort have been made to reach me.

Permission is also granted to Endeavor Church and its affiliates including directors, coaches, and helpers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered camp.
This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Please sign if you have read and agree to the above

Additional Information (select all that apply)