Clone of Kicking Bear Camp

Kicking Bear Adventure Day - Osseo Rod & Gun 2022

Registration Form - August 16th, 4:30PM to 9:30PM at Osseo Rod and Gun
This form must be signed by a PARENT or LEGAL GUARDIAN; one form can be submitted for each family. The Attendee does not have to be a legal guardian.
Choose one option; If you are bringing your own children as well as others, each parent/guardian needs to complete this form separately.
How many youth from your family will be attending?
Youth Name

First NameLast Name
Age of Youth
Age
Youth Name (Only fill in for additional children with same legal guardian)

First NameLast Name
Age of Youth
Age
Youth Name (Only fill in for additional children with same legal guardian)

First NameLast Name
Age of Youth
Youth Name (Only fill in for additional children with same legal guardian)

First NameLast Name
Age of Youth
Age
Youth Name (Only fill in for additional children with same legal guardian)

First NameLast Name
Age of Youth
Age

Address of Youth and Legal Guardian

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (Used to send reminders or updates on weather, etc.)
example@example.com
Note: This website is HIPAA compliant. May we administer regular first aid including ambulance if deemed appropriate?
Do you authorize hospital or doctor to administer necessary medical treatment?
Health Insurance Provider
Policy Number
Member Number
Additional Information
Emergency Medical Release Form
Release of Liability and Assumption of Risk Agreement
Photo/Video Release Form
Additional Comments or Questions.
Email info@kickingbear.org with any immediate questions or concerns.
Please follow our event on facebook at www.facebook.com/kickingbear1on1 to stay updated. See you there!!
Signature
Should be Empty:

Kicking Bear Adventure Day - Osseo Rod & Gun 2022