PVCC Camper Registration

Camper Information

Camper's Name *

First Name Last Name

Birth Date *

Month Day Year

Grade *

Gender *

Male Female

Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Home Church

Preferred Cabin Mates (List up to three)

Parent/Guardian Information

Name *

First Name Last Name

Home Number

Area Code Phone Number

Cell Number *

Area Code Phone Number

E-mail *

Emergency Information

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

Does camper have special dietary needs? *

No Gluten Free Vegetarian Lactose Intolerant

Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is camper taking any medications? *

No Yes

If yes, please input name of medicine and dosage into appropriate fields.

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Breakfast

Lunch

Dinner

Bedtime

Upon registering you will receive an email invoice listing the camp fee that you owe. It should come in a few days after regisration.

Informed Consent and Acknowledgement

As the parent or legal guardian of the registered minor(s), I, hereby attest that he/she/they is/are fully aware of the inherent hazards and risks and hereby elects to participate voluntarily and assumes all risks of loss, damage for injury that may be sustained by him/her/them.

GENERAL RELEASE AND WAIVER
Recreational activities, events and use of the Pleasant Valley Christian Camp (PVCC) grounds include, but are not limited to, the following: laser tag and equipment; basketball, baseball, soccer, and volleyball courts or fields; hiking trails, swimming pool; field games; archery; group games, campfires, arts and crafts, drama, music, a variety of athletic activities; and limited transportation on and off the grounds, etc. As the parent or legal guardian of the minor registrant(s), (participating in camp activities or events) I agree that they are physically able to participate in all camp activities based on a physician’s examination.

In exchange for the minor child(ren) being allowed to participate in recreational activities, events, and use of the “grounds” at PVCC, the parent or legal guardian for himself or herself and personal representatives, assigns, heirs and next of kin (herein referred to as releasors), hereby releases, holds harmless, indemnifies and defends PVCC (including PVCC agents, employees, and representatives) from any and all liability for injury or damages including, but not limited to, bodily injury, personal injury, emotional injury, or property damage which may result from any person using the above described property and participation in any activities, for registrant's purpose, unless such injury or damage results from the intentional, willful or reckless acts by PVCC (including PVCC agents, employees and representatives) or otherwise.

IMAGE RELEASE AND WAIVER
I give permission to PVCC to use any photographs, videos, and/or audio recordings of the participant for promotional materials, including the PVCC web site postings, without expectation of compensation, including, but not limited to, any royalties, proceeds, and/or other benefits derived from such photographs, videos, or audio recordings.

Medical Release and Authorization

As Parent and/or Guardian of the named camper, 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 athlete. 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 a reasonable effort has been made to reach me.

Permission is also granted to Pleasant Valley Christian Camp and its affiliates including Directors, Counselors, and Camp Staff 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 season.

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.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Junior Camper Registration Form