Mission Camp 2023 Registration Form

Summer 2023 Mission Camp Registration and Permission Slip
I am registering as:*
Teen Information
Teen's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Phone number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information (use for Adult Leader as well)
Name

First NameLast Name
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Do you/your teen have any allergies, chronic illness, or medical conditions? If yes, please describe.
Do you/your teen have any dietary restrictions? (Gluten-free, vegetarian, etc.)

Availability - June 19-22 (Hosted at St. Mary's Immaculate Conception)

Availability - July 17-20 (Hosted at Holy Angels)

Medical Information and Release

In the event of an emergency, I give permission to transport my child to a hospital for emergency medical treatment. I wish to be advised prior to any further treatment by the hospital or doctor.
Field Trip Consent and Release

In consideration for my child/ward’s participation, I agree to reimburse and indemnify the parish/school for all reasonable legal and court fees incurred by parish/school in defending a lawsuit that I or my child/ward may bring against the parish/school Which relates to the above named activity if the parish/school is found not legally liable by the courts and prevails in the lawsuit. If the parish/school is found legally liable for injuries sustained by child/ward, this paragraph will not apply.

I certify that I have an understanding of this agreement and any risks and hazards associated with the activity described above that my child/ward will be participating in. I further understand that I had the opportunity to fully discuss this agreement with a representative of the parish/school to clarify any concerns or questions about the activity or this agreement that I may have had.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature

Clear
Should be Empty:

Summer 2023 Mission Camp Registration and Permission Slip