TEENAGER INFO
Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
School Grade
*
Age
*
Gender
*
Female
Male
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Primary & Emergency Contact Information
Primary Contact Name
*
First Name
Last Name
Relationship to Child
*
Mother
Father
Uncle
Aunt
Grand Parent
Family Friend
Other
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Is the address same with the child?
*
Yes
No
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Information
*
Participant Health Information
Primary Care Physician Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Does the child have any medical conditions?
*
Yes
No
Please give details
Does the child have any allergies to food, medications, or insect bites?
*
Yes
No
Please give details
Medical Insurance Information
Insurance Company
Phone Number
Policy
Policy #
Group #
Policy Holder Name
Agreement & Consent
I, parent/guardian of the participant, agree with the following statements:
*
I give permission that my child may be photographed, videotaped, and/or interviewed for the purpose of the The River's promotional use.
I give consent for my child to be transported by The River to Winter Camp or emergency care.
Each child needs to bring their own snacks.
I agree to PRINT & SIGN the Woodland Hills Camp Release form and bring it back to Pastor's Tanner or Carly PRIOR to camp.
I understand that The Camp will not assume responsibility for any injury incurred while participating in athletic events,childcare programs, parent/child event and outings, special events, sports programs, or any related the camp sponsored activity.Certain risks of injury are inherent during participation in these programs and events. Nor will the the camp be responsible for any lost or stolen items while members and/or program participants are using the camp facilities, onthe camp premises, or on off-site camp program locations. I, the undersigned for myself and my heirs, do hereby release the camp and its employees and agents from any and all claims for injury, loss, or damage I may suffer as a resultof my participation. This includes any injury caused by negligence, if any, of the camp, its officers, employees, agents, volunteers,or the negligence of anyone else.
Date
-
Month
-
Day
Year
Date
Signature
*
My Products
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Winter Camp '24
1 Student Registration (February 16-18, 2024)
$
150.00
Quantity
1
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