2021-2022 Club Member Registration

2022-2023 Club Member Registration
Youth Member Information
Member (child) *

First Name Last Name
Gender *

Male Female
Age *
Birthdate *
Grade Fall 2022 *
Child's Address *

Street Address

Street Address Line 2

City State

Zip Code
How long have you been in Camp Fire Inland Northwest? *
What Club are you in: *
Parent/Guardian #1 Information
Parent / Guardian #1 *

First Name Last Name
Parent / Guardian #1 Address *

Street Address

Street Address Line 2

City State

Zip Code
Parent / Guardian #1 Phone Number *
Parent / Guardian #1 Work or Optional Phone Number *
Parent / Guardian #1 E-mail *

Confirmation Email
Parent/Guardian # 1 Occupation *
Parent/Guardian # 1 Employer *
Were you in Camp Fire as a child? *

Yes No
If "Yes", when were you in Camp Fire?
Parent/Guardian #2 Information
Parent / Guardian #2

First Name Last Name
Parent / Guardian #2 Address

Street Address

Street Address Line 2

City State

Zip Code
Parent / Guardian #2 Phone Number
Parent / Guardian #2 Work or Optional Phone Number
Parent / Guardian #2 E-mail

Confirmation Email
Parent/Guardian # 2 Occupation
Parent/Guardian # 2 Employer
Were you in Camp Fire as a child?

Yes No
If "Yes", when were you in Camp Fire?
Emergency Contact Information

Please provide information for teo people outisde of the home that we may contact in the event of an emergency and we cannot reach the parent/guardian.
Emergency Contact #1 *

First Name Last Name
Emergency Contact #1 - Relationship to child *
Emergency Contact #1 Number *
Emergency Contact #1 Other Phone *
Emergency Contact #2 *

First Name Last Name
Emergency Contact #2 - Relationship to child *
Emergency Contact #2 Number *
Emergency Contact #2 Other Phone *
List any adults authorized to drop off or pick up your child *
Are there any UNAUTHORIZED adults? *
Demographics

Please answer the following confidential questions to assist us in grant writing and funding. All answers are reported by agency totals, not by individual.
Race / Ethnicity *

American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Other Pacific Islander White (not Hispanic or Latino) Prefer not to provide
Annual Household Income *
Free/Reduced Lunch Status *
PARENT/GUARDIAN PERMISSION

I give my permission that my child (or ward) become a member of the Camp Fire Inland Northwest Council (hereafter "Council"). I will assist in observing the rules of the Council and I waive any claims against Camp Fire and the Council except for claims arising from gross negligence or willful acts of the Council or its agents that may arise from participation in the activities of the Council. I understand that reasonable measures will be taken to safeguard the health and safety of all participants and that I will be notified as soon as possible in case of any emergency affecting my child (or ward). In the event I cannot be reached in an emergency, I hereby authorize the calling of a physician to provide whatever emergency medical or surgical treatment is necessary. I accept responsibility for the cost of such medical treatments. I hereby agree and consent that Camp Fire Inland Northwest may publish, broadcast, and/or copyright, for all purposes, my child's (or ward's) statements and/or pictures taken of my child (or ward) and/or my child's (or ward's) property for advertising and public relations purposes, and I waive all claims for any compensation for such use.
Parent / Guardian Signature *

Clear
Membership Fee

Member registration is $30 per year per person. If you have left over candy credit from the 2022 sale available to use for the fee, select the second registration option. In the event you do not have enough available, a staff member from the Camp Fire office will contact you.

My Products

Member Registration Fee $ 30.00

Member Registration using Candy Credit Free

Total $ 0.00

Credit Card

Should be Empty: