Bar None Camp Registration 2023

Bar None Cowboy Church CAMPER REGISTRATION FORM
Which Camp is your child attending?*
Camper's Name*

First NameLast Name
Gender*

MF
Phone Number*
Email Address*
example@example.com
Address*

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Grade Completed (if student)*
Age*
Birthdate*

MonthDayYear
Date
Church*
Church City
T-Shirt Size*

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EMERGENCY CONTACT INFORMATION
Name (1)*
Relationship to Camper*
Phone*
Alternate Phone
Name (2)*
Relationship to Camper*
Phone*
Alternate Phone
Is camper current on all immunizations?*

YesNo
List relevant medical history/conditions that would help us meet the camper's needs:
Known allergies*
If None, type none.
Current medications*
If None, type none.
Is the student presently under a doctor's care?

YesNo
Doctor's Name
Doctor's Phone Number
Doctor's Address

Address

Street Address Line 2

City/State/ZipState / Province

Postal / Zip Code
Any special instructions
Parent/Guardian Name*
Parent Signature*

Clear
Date*

MonthDayYear
Date
AFCC RELEASE OF LIABILITY FORM
Parent Name*
Student Name*
Name of Camper*
Camper Signature*

Clear
Date*

MonthDayYear
Date
If the participant is younger than 18 then his/her parent or legal guardian must sign where indicated below. I am the Parent or Guardian of the aforementioned minor camper, and I verify by this signature the legal right to sign on behalf of the minor.
Name of Parent or Guardian*
Signature of Parent or Guardian*

Clear
Date*

MonthDayYear
Date
FOOD ALLERGY & SPECIAL DIET NEEDS

(Only Fill out if Necessary)
Does your child have food allergy or special diet needs?

YesNo
Camper Name
Age
Church
Parent's Name
Phone
Adult Sponsor
Adult Sponsor Phone Number
List FOOD allergies or explain special dietary needs
Is camper aware of his/her allergies?
Is camper able to monitor his/her own food requirements?
Walk on Water
Agreement to Participation
Assumption of Risk and Release of Liability
PLEASE READ BEFORE SIGNING
Signature of Participant (If Under 18, Parent or guardian must sign)*

Clear
Date*

MonthDayYear
Date
Name of Participant*
Bar None Emergency Medical Consent
Bar None Cowboy Church representatives have my permission to obtain emergency medical treatment for my camper when I cannot be reached or if a delay in reaching the camper can be dangerous for him/her.*
Mother/Father/Guardian/Emergency Contact(s) Name
Phone Number*
Please enter a valid phone number.
Phone Number
Please enter a valid phone number.
My child is taking the following medications:*
Enter None, if they are not currently taking medication.
My child has the following allergies:*
Enter None, if they have none.
I understand that I assume all financial responsibility for any treatment or injuries sustained by my child while he/she is in care.*

Yes
I grant BNCC Permission to the rights of photos of the above-named child/individual's image, likeness and sound of voice recorded on audio or video with no payment or any other consideration. I waive the right to any royalities or other compensation. These images may be used by BNCC with or without the name of the individual named above in any lawful purposes. There is no limit on the validity of this release. By signing below, I hereby release, defer, hold harmless, and indemnify Bar None Cowboy Church from any and all claims utilizing this material.*

Yes
Signature of Parent/Guardian if child is under 17*

Clear
Date*

MonthDayYear
Date
Please Share any information that would help us make your child's camp experience the best it can be (Ex: Scared of Dark, Autism, Sensitive to Noise, etc)*
Payment
How much would you like to pay:*

Deposit PreTeen: $50 (nonrefundable)PreTeen: Full Payment $340 (Includes $15 Shirt Fee)Deposit Teen: $50 (nonrefundable)Teen: Full Payment $340 (Includes $15 Short Fee)Scholarship (Cody Bishop or Ryan Landreneaux will be in contact)Adult ChaperonePay Cash/Check in Church Office
I would like to set up the following payment plan to pay the remaining balance:*
(This will not be put on automatic draft, just when reminders will be sent for unpaid balances)
Total
How Much would you like to pay towards your students camp?*

prevnext( X )
USDChurch Camp

Should be Empty:

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Bar None Cowboy Church CAMPER REGISTRATION FORM

EMERGENCY CONTACT INFORMATION

AFCC RELEASE OF LIABILITY FORM

FOOD ALLERGY & SPECIAL DIET NEEDS

Bar None Emergency Medical Consent

Payment