Kicking Bear Camp - West Salem 2022

Kicking Bear Adventure Day - West Salem 2022

Registration Form - July 29th at Maple Grove Venues
This form must be signed by a PARENT or LEGAL GUARDIAN; one form can be submitted for each family. The Attendee does not have to be a legal guardian.
Choose one option; If you are bringing your own children as well as others, each parent/guardian needs to complete this form separately.*

Parents or legal guardians will be responsible for the registered youth.A friend, adult family member, or mentor of the youth will be responsible.
How many youth from your family will be attending?*
Youth Name*

First NameLast Name
Age of Youth*
Age
Youth Name (Only fill in for additional children with same legal guardian)

First NameLast Name
Age of Youth
Age
Youth Name (Only fill in for additional children with same legal guardian)

First NameLast Name
Age of Youth
Youth Name (Only fill in for additional children with same legal guardian)

First NameLast Name
Age of Youth
Age
Youth Name (Only fill in for additional children with same legal guardian)

First NameLast Name
Age of Youth
Age

How many adults (parents or mentors) will be attending?*
First Parent or Legal Guardian 1: Name*

First NameLast Name
Parent or Legal Guardian 1: Phone Number*

Area CodePhone Number
Parent, Legal Guardian, or Attendee 2: Name

First NameLast Name
Parent, Legal Guardian, or Attendee 2: Phone Number

Area CodePhone Number
Parent, Legal Guardian, or Attendee 3: Name

First NameLast Name
Parent, Legal Guardian or Attendee 3: Phone Number

Area CodePhone Number
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number

Address of Youth and Legal Guardian*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (Used to send reminders or updates on weather, etc.)*
example@example.com
Note: This website is HIPAA compliant. May we administer regular first aid including ambulance if deemed appropriate?*

YesNo
Do you authorize hospital or doctor to administer necessary medical treatment?*

YesNo
Health Insurance Provider
Policy Number
Member Number
Additional Information
As the parent or legal guardian, I acknowledge that the above information is to be used in lieu of an Emergency Medical Release Form(see below), and that the Attending Adult named is responsible for my child/children while at camp if different from parent.
Emergency Medical Release Form
As the parent or legal guardian, I have read the Release of Liability and Assumption of Risk Agreement (see below), and I fully understand its terms, and understand that I have given up legal rights by clicking and signing this form, and I do so freely and voluntarily without any inducement.
Release of Liability and Assumption of Risk Agreement
As parent or legal guardian, I have read the Photo/Video Release Form (see below) and understand that if I DO NOT wish to have my child's image used by Kicking Bear, it is my responsibility to notify the host Kicking Bear team at check-in/registration.
Photo/Video Release Form
Additional Comments or Questions.
Email info@kickingbear.org with any immediate questions or concerns.
Please follow our event on facebook at www.facebook.com/kickingbear1on1 to stay updated. See you there!!
Signature*

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Kicking Bear Adventure Day - West Salem 2022