X-treme Summer 2022

Date

Month Day Year
Date
Registration X-Treme Summer 2022
YOU WANT / USTED QUIERE

Register a student for the FIRST TIME / Registrar un estudiante POR PRIMERA VEZ The student is already registered and I want to pay more weeks / El estudiante ya esta registrado y quiero pagar más semanas.

Click here

Instructions to fill out this form
Take into account that this registration contains sections that will require electronic signatures (-signatures) that can only be placed by the parent or legal guardian of the participant child. Since you are filling out this form on behalf of a minor, you must be the parent or the legal guardian of the minor for whom this form is being filled out.

It is intended that this form complies with the Security Procedures and the statutes under Florida Statutes 668.50, and any other State or Federal Law with regards to e-signatures.

This form has 5 sections:

1- Registration information

2- Personal Information of the participant child and his or her parents or legal guardians,

3- Waivers (2)

4-Medical Condition Report and swimming disclosure.

5-Payment Section, with the following conditions:

a) Pay the registration fee of $40. This is non-refundable and it is selected by default.

b) Select the individual weeks you would like your child to attend the camp. Each week investment is $140

The first 4 sections must be completely filled out in order to access the payment section. This form can be completed in 15 to 20 minutes.

Information | Información

OF THE PERSON WHO IS FILLING OUT THIS FORM | DE LA PERSONA QUE LLENA ESTA REGISTRACIÓN
Name of the person who is filling out this form *

First Name Last Name
Your email *
Relationship with student *

Father Mother Legal guardian
Grade that the student completed by June 2022 *
Campus Hours *

Until 3:00 P.M
Please mark which weeks the student will be attending *

Week 1 / semana 1 - June 20th – 24th Week 2 / semana 2 - June 27th – July 1st Week 3 / Semana 3 - July 11th - 15th Week 4 / Semana 4 - July 18th – 22nd
# of Weeks
THE WEEK OF JULY 4TH WE WILL BE CLOSED DUE TO INDEPENDENCE DAY

LA SEMANA DE JULIO 4 ESTAREMOS CERRADOS POR EL DIA DE LA INDEPENDENCIA

Please go over the required fields below. If you are not able to fill out this section completely with all required information, you will need to personally register the student at Summer Adventure headquarters at

Iglesia Community
8527 Pines Blvd,
Pembroke Pines, FL 33024

Phone: 954 538 9788
Father's Information
Father's Name *

First Name Last Name
Is the address the same as the student? ¿Es la dirección la misma que el estudiante?

Yes/Si
Address *

Street Address

Street Address Line 2

City State

Zip Code
Cell Number *
Home Phone
E-mail *

Confirmation Email
Mother's Information
Mother's Name *

First Name Last Name
Is the address the same as the student? ¿Es la dirección la misma que el estudiante?

Yes/Si
Address *

Street Address

Street Address Line 2

City State

Zip Code
Cell Number *
E-mail *

Confirmation Email

Emergency Contacts
Name Emergency Contact *

First Name Last Name
Cell Number *
Relationship with the Child *

Do you have medical insurance? *

Yes No
Insurance Company *
Group # *
Member # *
Phone Number of the Insurance Company *
Name of the Primary Doctor *

First Name Last Name
Phone Number of Primary Doctor *
You have finished section 1. Next Section: "Waiver"

You are about to read very important documents: 2 waivers and 1 medical condition report of the participant child. Read carefully and sign.

If you are using a Personal Computer (PC) you can sign by using the mouse or the pad (laptop), if you are using a smart phone or tablet, you can sign with your finger.
Notice about eSignatures
I hereby certify the following:

1- I am the Parent or legal guardian of the minor participant or I am the participant and I am older than 18 years old.

2- I am not signing the following forms on behalf of anybody else, unless I am signing the minor participant , for which I am Parent or legal guardian.

3- I am legally authorized to sign this form.

It is intended that this form comply with the Security Procedures and the statutes un der Florida Statutes 668.50, and any other State or Federal Law with regards to esignatures.
Signature *
Name *

First Name Last Name

SECTION 2 - WAIVER 1/2
Read carefully

The undersigned has agreed to partake in an activity, and or trip which is referred to as follows. If the participant is a minor, then their parent or legal guardian has agreed and signed below.

The Activity is: X-TREME SUMMER 2022
The Participant is: {nameOf8}

WAIVER, RELEASE OF LIABILITY, INDEMNIFICATION, AND CONSENT TO MEDICAL ATTENTION

1. In the event of an emergency, I would request that you contact the person named in the Emergency Contact section of the online form and/or named below, if for myself, but if on behalf of my minor child, please contact me at the contact information provided.

2. I hereby agreed to hold COMUNIDAD CRISTIANA P.P., its agents, employees, and/or volunteers harmless from any and all injuries, accidents, costs, losses, causes of action, claims, damages, and/or liability that may result from the participation in the above activity, the transportation to and from the Activity, and in general everything having to do with the Activity. I understand that participation in the above activity is strictly voluntary and I am willing to assume all of the potential risks involved in the Activity on my behalf or on behalf of my minor child.

3. I agree that COMUNIDAD CRISTIANA P.P. is not responsible for the medical care or insurance coverage for any injury, accident, or medical emergency that may occur as a result of the participation or transportation to and from said Activity, by me or my minor child.

4. I am aware and agree that no insurance or medical care coverage has been obtained by COMUNIDAD CRISTIANA P.P. for me or on my behalf, or on behalf of my minor child

5. I agree that I have medical coverage or insurance, for me or my minor child, in the event of an emergency, and if I do not have medical coverage or insurance for me or my minor child, then I shall take full responsibility for any and all costs of medical care or treatment, in the unlikely event of a medical emergency.

6. I recognize that in the event do, or cause to be done, or participate in any action that is unbecoming of the nature of the activity, in other words, if I do anything that negatively reflects upon COMUNIDAD CRISTIANA P.P. COMUNIDAD CRISTIANA P.P. reserves all rights to bring legal action against me for any harm I may have caused to its name and/or image.

7. I recognize that we are in the middle of a pandemic known as COVID19 and that I release COMUNIDAD CRISTIANA P.P, and its representatives, agents, employees, and/or other volunteers harmless from any and all Covid-19 related injuries, accidents, costs, losses, causes of action, claims, damages and/or liability that may result from the attendance at one of our church services. I understand the Covid-19 related risks and I am willing to assume all of the potential risks related thereto on my behalf or on behalf of my minor child.

8. I have read and agree to all of the above, and I choose to partake in the above activity (if over the age of 18) or give permission for the registered minor to partake in the above activity.

I HEREBY SIGN THIS WAIVER OF LIABILITY AND CONSENT TO PARTAKE IN THE ABOVE ACTIVITY, ON BEHALF OF MYSELF OR ON BEHALF OF MY MINOR CHILD, AND IN SO DOING FULLY UNDERSTAND THAT I WILL NOT HOLD COMUNIDAD CRISTIANA P.P. ITS EMPLOYEES, AGENTS, AND/OR VOLUNTEERS, RESPONSIBLE FOR ANY INJURIES, ACCIDENTS, COSTS, LOSSES, CAUSES OF ACTION, CLAIMS, DAMAGES AND/OR LIABILITY THAT MAY RESULT FROM THE PARTICIPATION IN THE ABOVE ACTIVITY AND/OR THE TRANSPORTATION TO AND FROM THE ACTIVITY.
Initials / Iniciales *
When you write your initials above, you are acepting each an everyone of the points stated above in the waiver. An email with a copie of this waiver will be sent shortly after registration.
Signature *

Section 2 (cont.) Waiver 2/2
Read carefully

CHILD PERMISSION TO PARTICIPATE IN CAMP ACTIVITIES

I HEREBY GRANT PERMISSION FOR MY CHILD for whom this form is filled out and whose name has been detailed in the information section on the online form, to attend off-campus activities sponsored by Comunidad Cristina and Summer Adventure. I also acknowledge that Comunidad Cristiana and Summer Adventure are not responsible for injury or loss of personal belongings on these trips.

My child and I understand that if they do not follow directions, they can be sent home at the director’s discretion and they will not receive a refund.

In the event that my child becomes ill or injured while under the Camp’s supervision, I authorize the leader or their designee to take the following steps:

1. Contact the parents of the child immediately and follow his or her instructions.

2. In the event that neither parent can be reached, comunidad will contact the 2nd emergency contact and/ or the child’s physician and follow their instructions. In the event that these contacts cannot be reached, comunidad will call 911.

3. If the child needs medical or surgical services which require the parent’s consent and the parents cannot be reached, I, the parents hereby authorize, appoint, and empower the director or their designee to famish on my behalf such written or oral authorization as may be required.

4. I release the director or their leader, comunidad Cristiana Summer Adventure from any liability which arises from the granting of such authorization since it is my de that my child receives medical attention as soon as possible.

5. I give permission for the participant’s picture, while partic in camp activities, to be used in brochures, publications, sli videos promoting comunidad Cristians and Summer Adventure.
Initials / Iniciales *
When you write your initials above, you are acepting each an everyone of the points stated above in the waiver. An email with a copie of this waiver will be sent shortly after registration.
Signature *

Finish this part of the registration with your complete name below. When you click on "Next", you will be conected to the payment section.
You have finished section 3. Next Section: "Payment"
Notes:

At this time, you can pay the registration fee only or if you wish, you can also add one option. The detailed week(s) was(were) selected in Section 1.

You Selected:

# Week(s): {Of} Until: {campusHours}

You are paying: *

Registration Fee

$ 40.00

Add 1 Week | Agregar 1 Semana

$ 100.00

Add 2 weeks | Agregue 2 Semanas

$ 240.00

Add 3 weeks | Agregue 3 Semanas

$ 380.00

Add 4 Weeks | Agregue 4 Semanas (Save $20)

$ 460.00

Enter coupon

Total

$ 0.00

After payment has been sumbitted, click "return to merchant" in the Paypal payment confirmation prompt or wait for a few seconds.
Should be Empty:

	Yes	No
1. Heart trouble
2. Bronchitis
3. Sinusitis
4. Kidney Trouble
5. Hay Fever
6. Dizziness
7. Social disorders
8. Stomach trouble
9. Food Allergy
11. Insect stings/bites
12. Medication

Registration X-Treme Summer 2022

Instructions to fill out this form

Information | Información

SECTION 1 PERSONAL INFORMATION OF THE

Father's Information

Mother's Information

Emergency Contacts

SECTION 2 - WAIVER 1/2

Section 2 (cont.) Waiver 2/2

Section 3, Medical Condition Report and Swimming disclosure