Summer Reconnect Online Signup

Summer Reconnect Online Signup

An Eastside Church of Christ event beginning Thursday July 30 and ending August 2nd hosted at Camp Wabashi.
Registration Information

All Campers must have a filled out online Registration Form by July 19th, 2020. Dropoff/registration begins at 5:30EST and ends at 7:00PM EST. All Campers must have their own individual registration form filled out. Walk up registrations will have an additional late fee of 15 dollars to cover added food costs.
Pick-up Information

Summer Reconnect will end Agust 2nd at 3:00 PM. Please do not arrive before this time unless necessary. Please have your student picked up by 4:30PM EST.
Camper's Name *

First Name Last Name
Camper Date of Birth *

Month Day Year
Date
Camper's Current Age *
Camper's Last Finished Grade *
Camper's Gender *
Camper's Home Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian Phone (Cell) *

Area Code Phone Number
Parent/Guardian Phone #2 *

Area Code Phone Number
Parent/Guardian Phone #3

Area Code Phone Number
Camper Cell if Applicable

Area Code Phone Number
Parent/Guardian Email *
example@example.com
Camper Email if Applicable
example@example.com
Church Congregation Attended *
Has Camper been Baptized *
Parent/Guardian Name *
Relationship to Camper *
CONSENT FOR MEDICAL TREATMENT OF A MINOR CHILD

I herewith authorize Eastside Church of Christ staff at Eastside Church of Christ events to request and consent in writing or otherwise as requested by Union Hospital, Inc. and/or any other medical facility to any and all examinations, medical treatment and/or procedures to or for the above named minor, either on or off the premises of medical facility, as deemed advisable or appropriate by any physician or surgeon licensed to practice medicine in the State of Indiana. I understand that verbal consent will be sought using the phone numbers listed in this application.

In consideration of the acceptance of the above-named camper, I covenant and agree with Eastside Church of Christ, that I will at all times hereafter indemnify, and save harmless the said Eastside Church of Christ from all actions, proceedings, claims, demands, costs, damages and expenses which may be brought against, or claimed from Eastside Church of Christ, or which it may pay, sustain, or incur as a result of illness, accident, or misadventure to the above named camper during the period said camper is a participant in the Eastside Church of Christ.

This authorization constitutes a Power of Attorney and waiver of liability appointing the above named adult or staff of Eastside Church of Christ as Attorney-In-Fact to sign said requests and as fully thought I, myself, did so.

This is effective from the dates of July 30th 2020 through August 2nd 2020.
ONLINE SIGNATURE (Type name) *
COVID 19 DISCLAIMER

I understand the risks associated with Covid-19 and that by attending this event my child may be at risk for contracting Covid-19 even with safeguards and procedures in place. In consideration of the acceptance of the above-named camper, I covenant and agree with Eastside Church of Christ, that I will at all times hereafter indemnify, and save harmless the said Eastside Church of Christ from all actions, proceedings, claims, demands, costs, damages and expenses which may be brought against, or claimed from Eastside Church of Christ, or which it may pay, sustain, or incur as a result of contracting Covid-19.
ONLINE SIGNATURE (type name) *
The undersigned also gives permission to Eastside Church of Christ to take photographs and video images of my child during Summer Reconnect and to use these images along with the child’s first name in our publications, advertising and on our website. I agree that neither my child nor I will receive any compensation, royalty or fee for these and that all rights, title and interest to them shall belong to Eastside Church of Christ, who may publish them indefinitely.
ONLINE SIGNATURE (type name) *
MEDICAL INSURANCE INFORMATION
Medical Insurance Carrier *
Member's Name *
Relationship *
Account Number
Benefit Code
Expiration Date

Month Day Year
Date
Medical History *
Allergies (Food and Medicine) *
Chronic or Existing Diseases *
Medicines Camper is Taking Now *
I affirm that all above information is true. Signature Below: *

Clear
PRICING:

The Cost of Summer Reconnect is 75 dollars for all food and housing. This payment can be made two ways:

1) Sent to Eastside Church of Christ via mail (Please send before July 19th so we have time to receive it.) Please make your check payable to Eastside Church of Christ.

Please send the mail to the following:

Eastside Church of Christ
ATTN: Josh Morford
4025 College Ave

Terre Haute IN 47803.

Please include in the mail which camper/camper's the check is for.

2) In-person at Registration. As long as you have filled out this form ahead of tiem there is no additional cost to pay at event-start. Please make checks payable to Eastside Church of Christ.

thank you
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Summer Reconnect Online Signup

Registration Information

Pick-up Information