PV Camp on the Mesa Consent Form

PV Camp on the Mesa Consent Form

Mission Possible July 28-31, 2024 26269 Old Grand Mesa Rd Cedaredge, CO 81413
Join us on the beautiful Grand Mesa as we fish, boat, run, play laser tag and disc golf, create crafts, make new friends and learn about how with Jesus all things are possible. This is a 3 day camp for students going into the 2nd through 6th grade.
Name of Camper*

First NameLast Name
Email*
example@example.com
Camper's Date of birth*

MonthDayYear
Grade your child is going into fall of 2024:*
Gender

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Youth T-shirt Size*
Medical Information
Does your child have special instructions for medical treatment? If yes, please explain including the medication your child is taking*
Are there any activities that you wish your camper to not participate in? Please explain below*
Does your camper have or had any medical concerns we need to be aware of? Please explain below*
Name of Doctor*

First NameLast Name
Doctor Phone Number*

Area CodePhone Number
Consent and Authorization
I, the undersigned, hereby declare and affirm that:

I am the parent/legal guardian of the youth named above (hereinafter referred to as "Child"), who is under my care and responsibility.

I hereby consent and give authority to the participation of my Child in the scheduled youth activities of the Camp, and all other activities which is supervised and customarily associated with its group.

I hereby declare and affirm that my Child is physically fit to take part in the Camp's activities and my Child has no known illness or adverse medical condition that would render him/her unfit to participate therein, other than the information specified in the medical information above.

I shall immediately advise the organizers in writing, should I discover any illness, adverse medical condition, or any other physical injury that would render my Child unfit to participate in the recreational and sporting activities of the Camp.

I shall notify the organizers immediately in case I revoke my consent to the Camp for this event.

Authorization for Medical Treatment

I understand that in case of medical emergencies involving my Child, I shall be notified right away. In case any of my provided contact information is unreachable, I authorize the organization to call the doctor indicated above. In case that the doctor is not available, I authorize the organizers to call any doctor to provide the necessary medical attention to my child.

I understand that the camp shall not be responsible, and shall be reimbursed, for any medical expenses incurred by them over this authorization.
I authorize Molina Baptist Church to utilize pictures of my child taken during camp for marketing purposes.*

YesNo
Name of Parent/Guardian*

First NameLast Name
Contact Number*

Area CodePhone Number
Signature of Parent/Guardian*

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$100 camp registration fee can be paid in cash or check to Molina Baptist Church. Please reach out for information on partial scholarships if needed.
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PV Camp on the Mesa Consent Form

Medical Information

Consent and Authorization