Xtreme Challenge Camp

Youth Camper Registration Form

All Registration Forms Due by: May 29th, 2023

Registration Fee: $145.00 ($45.00 with Scholarship)

Full payment must be received by: May 29th, 2023

Please submit payment by our office at 505 W Belknap St. or mail to PO BOX 425, Jacksboro, TX

INSTRUCTIONS: Please use one form per registrant and

*fill out the form completely.

Youth Campers are responsible for submitting their Registration, Medical Release, and Transportation/Phote Release Forms, with parent/guardian signatures prior to/or by May 29th, 2023.

School*

Camper Name*

Date of Birth*

Date

Grade Level Completed This School Year*

Parent/guardian Name*

Parent/Guardian Phone #*

Format: (000) 000-0000.

Parent/Guardian Email*

example@example.com

Address*

City*

State*

Zip*

T-Shirt Size S/M/L/XL/XXL*

Other Size

My camper needs a $100 scholarship Yes/No*

June 5th-9th Jack County STOMP

P.O. Box 425 Jacksboro, TX 76458

Dear Parents/Guardians,

Jack County STOMP is pleased to invite your child, who has completed 6th through 8th grade, to participate in the XTREME Challenge Camp for 2023. The camp will take place here in Jacksboro June 5th-9th from 8am-5pm with some out of town evening activities: see schedule (transportation around town and to out of town events will be provided). Also, lunch will be provided each day of camp by local churches.

*A parent/guardian will need to sign your child out each day after activities are concluded.

In this form, you will find the following information which will assist you in preparing for your child's camp experience: XTREME Challenge Camp Parent Letter, Medical Release Form, Transportation/Photo Release Form, & Camp Liability Waiver.

*XTREME Challenge Camp Daily Itinerary/Weekly Schedule provided on Day 1.

In order to maintain high standards of camper safety, everyone who participates in our programs must Register on our website @jackcountystomp.org Spots are reserved by payment in full by: May 29, 2022.

All Registration Forms Due by: May 29th Registration Fee: $145.00

*If you need financial assistance, scholarships are available.

While at camp, your child will experience many great things throughout the week and learn skills such as CPR (will receive junior certification), fire safety and rescue, outdoor survival skills, teamwork, and much more from our local, highly trained emergency personnel and community leaders. These leaders include: Faith Community Hospital EMS, Jacksboro Police Department, Jacksboro Fire Department, Jack County Sheriff's Department, Jack County Game Warden, Jacksboro ISD coach staff, Fort Richardson Park Ranger/staff, and Jack County STOMP members/volunteers.

To ensure the enjoyment and safety of all campers, XTREME Challenge Camp reserves the right to dismiss campers in the unlikely event of a discipline issue. Parents or guardians will be contacted by phone to arrange child pickup. No refund will be granted to those unable to complete a camp. Also, to ensure camper safety, please talk with your child about the importance of wearing sunscreen to avoid sunburn from outside activities and encourage them to drink plenty of water to stay hydrated.

*Camp takes place rain or shine, so please make sure your child wears/brings appropriate clothing for the daily activities.

Check-in and first day registration is Monday, June 5th. Please arrive with your child at the Twin Lakes Activity Center (daily drop-off location) by 7:45am.

*You will need to come in with your child on the first day.

For the remaining camp days (6th-9th), 2023 XTREME Challenge Camp begins at 8am. Please have your child at the daily drop-off location on time, so that camp may begin on time each day.

If you have any additional questions, after reading all of the materials, feel free to call (940) 507-5110 or email us at jackcountystomp@gmail.com

We look forward to seeing your child this summer and challenging them to become an even stronger leader.

Thank you,

Linda Bennett

Jack County STOMP Founder/Director

Liability/Medical Release Form

In consideration for my child to be accepted into the STOMP XTREME Challenge Camp I, the parent/legal guardian, do on behalf of my child-participant hereby release, forever discharge and agree to hold harmless STOMP XTREME Challenge Camp, Jack County STOMP and the directors, from any and all liability. Liability includes: claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned/child-participant that occurs while said camper is participating in the camp. Furthermore, I on behalf of my child hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in any/all camp activities. Furthermore, authorization and permission is hereby given to Jack County STOMP to furnish any necessary transportation, food and lodging to this participant. The undersigned further agrees to hold harmless and indemnify Jack County STOMP, its directors, employees, volunteers and participating agents, from any liability sustained by said organization as the result of negligent, willful or intentional act of the child-participant, as well as expenses incurred attendant thereto.

yesno

Camper Name*

Parent/guardian signature*

I hereby grant permission for him/her to participate fully in camp activities, evaluation and assessment of camp experience including demographies/personal information I hereby give permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility for all medical bills. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, I hereby assume all transportation costs.

Parent/guardian signature*

Do you have Medical Insurance?

IF YES, PLEASE BRING A COPY OF YOUR INSURANCE CARD THE OPENING DAY OF CAMP

Insurance Company

Policy #

Contact Info

Physician #

I, the parent/legal guardian, understand the onsite camp medical staff and/or an adult sponsor may administer any required medication to my child if needed.

Signature*

Does your child take medication? if Yes, please specify*

Does the child have any allergies (food, medical, etc?)

Yes

No

If YES, please specify

In case of emergency, who should be notified? (Please provide two emergency contact persons below; make sure one is someone other than a Parent/Guardian):

Name*

Relationship*

Phone*

Format: (000) 000-0000.

Name*

Relationship*

Phone*

Format: (000) 000-0000.

Transportation Permission

We are looking forward to having your teen attend STOMP XTREME Challenge Camp. To ensure your child's safety, we need to know whom you've given permission to pick up your child if you are unable to. Please fill in this information below.

Authorized person #1*

Authorized person #2*

Photo Release

We would appreciate permission to use photos taken during camp to publicize our programs. If you are willing for us to use any photos your child may be in, please sign below.

*Youth may be identified by name in our publications

I give permission to Jack County STOMP to use any photos taken during STOMP XTREME Challenge Camp for promotional materials(i.e.:publications, Facebook, Instagram, Website, news releases, etc.)

yesno

Camper Name*

Parent/Guardian Printed Name*

Parent/Guardian Signature*