CampRISE Respite Care

Childs Name:*

First NameLast Name

Second Child:

First NameLast Name

Third Child:

First NameLast Name

Parents Name:*

First NameLast Name

Address:*

Street Address

Street Address Line 2

CityState

Zip CodeCountry

Phone Number:*

Please enter a valid phone number.

Email Address:*

Emergency Contact Information*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Child/Children age range:*

4-6 Years6-9 Years9-13 Years

Please list any allergies and/or food restrictions:*

Doctor Information:*

First NameLast Name

Phone Number*

Please enter a valid phone number.

Funding Information if applicable:

In CommunityBobby DobbsOther

Please indicate if photographs are allowed:*

YESNO

I acknowledge the of risk as the parent/guardian of the minor named, do hereby acknowledge, and agree that participation in youth program activities conducted or sponsored by Camp Rise at Buford Kids Spot (Facility), and its subsidiaries and affiliates, and its past or present officers, directors, managers, employees, supervisors, agents, or representatives and assigns (collectively known as the “Camp Rise” comes with inherent risks. I have full knowledge and understanding of the inherent risks associated risks with the program and participation, including but in no way limited to: (1) slips, trips, and falls, (2) aquatic injuries, (3) athletic injuries, and (4) illness, including exposure to viruses or bacteria. I further acknowledge that the preceding list is not inclusive of all possible risks associated with camp participation and that said list in no way limits the operation of this Agreement.

Disclaimer:*

I Agree

Signature