Camp Motion 2021

Your Name *

First Name Last Name

Phone Number *

Area Code Phone Number

E-mail *

Address

Street Address

Street Address Line 2

City State

Zip Code

==========Information for first child==========

#1 Child's Name *

First Name Last Name

#1 Gender *

Girl Boy

#1 Age *

#1 Grade this Fall *

#1 Preferred Camp *

#1 Shirt Size *

Special Needs (all children) *

==========Information for second child==========

#2 Child's Name

First Name Last Name

#2 Gender *

Girl Boy

#2 Age

#2 Grade this Fall

#2 Preferred Camp *

#2 Shirt Size *

==========Information for third child==========

#3 Child's Name

First Name Last Name

#3 Gender *

Girl Boy

#3 Age

#3 Grade this Fall

#3 Preferred Camp *

#3 Shirt Size *

==========Emergency Contact Information==========

Emergency Contact *

First Name Last Name

Emergency Phone Number *

Area Code Phone Number

Please provide the names of anyone other than yourself who is authorized to pick up the campers.

e.g., spouse's name, grandparent's name, etc.

====================

Payment *

Pay Later with check or cash Pay online now with a credit card

Pay now with a credit card

Register (1) One Child $ 80.00

Register (2) Two Children $ 160.00

Register (3) Three Children $ 240.00

Enter coupon

Total $ 0.00

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Date	Postal Code

Please mail or bring your payment to:

Wellspring Family Church

5293 South Lindbergh Blvd.

St Louis, MO 63126

The cost is $80 for one child, $160 for two children, or $240 for three children

How did you hear about us this year? *

Postcard Church sign Church website email from church From a friend Online ad

Participation / Publicity Waivers

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Participation / Publicity Waivers

I hereby request that the child/children listed in the form above be admitted to Camp Motion and authorize and direct camp staff to exercise and act in their best judgment in the event of any medical emergency regarding the child/children. I also confirm that the child is covered by accident insurance which provides coverage for any accidental bodily injury. By accepting this waiver below, I hereby agree to hold harmless Wellspring Family Church (WFC) and any of its agents and/or employees in connection with any incident or occurrence arising out of the child’s enrollment in Camp Motion.

Camp Motion occasionally takes photos/videos of our campers for publication to our website, social media, or community media sources. By accepting this waiver below, I give permission for WFC to use pictures and/or video of the child/children listed in the form above for the above-mentioned purposes.

COVID-19 has been declared a worldwide pandemic by the World Health Organization and the Centers for Disease Control. COVID-19 is contagious and is believed to spread mainly from person-to-person contact, as well as through surface contact. As a result, federal and state governments and health agencies recommend social distancing. Neither WFC nor Camp Motion can guarantee that you, your family, and Camp Motion participants enrolled by you will not become infected with COVID-19 or any other infectious disease as a result of attending camp. You acknowledge that the WFC and Camp Motion liability insurance may not provide coverage for contracting an infectious disease. You also acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that you and/or members of your family, and Camp Motion participants enrolled by you may be exposed to or infected by COVID-19 or other infectious disease as a result of attending camp and that such exposure or infection may result in personal injury, illness, permanent disability, or death.

You agree to assume all of the aforementioned risks and accept sole responsibility for any injury to yourself, Camp Motion participants enrolled by you, and members of your family, (including, but not limited to, personal injury, disability, and death, illness, damage, loss, claim, liability, or expense of any kind) that you or they may experience or incur in connection with the use of the property or community amenities related to the property.

You hereby release and covenant not to sue, discharge, and agree to defend and hold harmless WFC and its agents and/or employees from all claims, including all liabilities, claims, actions, damages, costs or expenses of any kind including reasonable attorney’s fees and court costs, arising out of or relating to the contraction of COVID-19 or other infectious disease.

You understand and agree that this release includes any claims based on the actions, omissions, or negligence of WFC and Camp Motion and any of their respective employees, directors, volunteers and representatives.

By signing this form I agree to fully abide by the terms in the above waivers. *

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