KIDS CAMP Registration Form

Name*

Student First NameStudent Last Name

Student Email

example@example.com

Student Phone #

Student Address*

Student School*

Student Grade*

Student Birth Date*

Date

Parent Guardian 1 Name*

Parent Guardian #1 Phone Number*

Parent Guardian 1 Email*

example@example.com

Parent Guardian 1 Address*

I give TwentyEight:19 and its partners permission to communicate via phone or email.*

Permission granted

Parent Guardian 2 Name

Parent Guardian #2 Phone Number

Parent Guardian 2 Email

example@example.com

Parent Guardian 2 Address

Name anyone else we should contact in the event of an emergency.

Name

Phone Number

Address

Date of the students last physical exam*

Date

Date of last tetanus shot

Date

List any medications your child uses*

List any dietary restrictions or allergies*

Photo Release & Transportation*

I give TwentyEight 19 and its partners the permission to use my child's picture or videos that include my child for promotional purposes such as email lists or in social media postsBy checking the line to the left, I give TwentyEight: 19 and its partners permission to transport my child to and from programs and events as long as the driver has been authorized by TwentyEight: 19 and its partners to do SO. I understand that anyone authorized by TwentyEight: 19 and its partners to transport students has been background checked with the inclusion of an MVR report.

STUDENT CONTRACT

Never Go Alone At all times, stay with your team and work with your team. Never go off by yourself.

Safety Practice the safety guidelines that you are taught.

Listen Listen to others. Listen to your peers and your leaders. Listen actively by maintaining eye contact and interacting with what they are saying.

Makers of Peace In all situations, look for opportunities to make peace. Help others work towards peace or get a leader involved to help make peace wherever there is conflict.

Follow Instruction If your leader tells you or shows you how to do something, do it in that manner.

Eager to Learn Look for opportunities to learn something new. If you are struggling with something, stay positive and believe in your ability to problem solve!

Integrity Always do the right thing, especially when no one is watching.

Be Real In every situation, tell the truth and give others the chance to share the truth. Do not deceive yourself or others.

Responsibility Be dependable. Do as you say. Own your words and your actions. Live with them, learn from them, and use them well. Give people a reason to trust your character.

Respect Treat yourself and others like you are made in God's image because it's true!

Righteous Strive to be pure in your heart. Make good decisions that reflect that purity.

Trustworthy Can people put faith in you? Follow through on your commitments and be there for others.

By signing below, you and your student acknowledge that you've read this contract and agree to abide by it.

Release of Liability & Permission to Secure Treatment

I recognize and acknowledge that there are certain risks of physical injury to participants in the above program(s) and I agree to assume the full risk of any injuries, damages, or loss regardless of severity which I or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with such program(s I agree to waive and relinquish all claims I or my minor child/ward may have against TwentyEight: 19 and its affiliates, officers, agents, volunteers, employees, and any companies associated as a result of participation in the program.

I do hereby fully release and discharge TwentyEight: 19, its affiliates, officers, agents, volunteers, and employees from any and all claims from injury, damage, or loss with the activities of the program(s I further agree to indemnify and hold harmless and defend its officers, agents, volunteers, and employees from any and all claims resulting from injuries, damages, and losses sustained by me or my minor child arising from, connected with, or in any way associated with the activities of the program(s).

In the event of any emergency, I authorize TwentyEight:19 and its partners to secure from any licensed hospital, physician, and/or medical personnel any treatment deemed necessary for me or my minor child/ward's immediate care and agree that I will be responsible for payment of any and all medical services rendered.

Signing your name below indicates that you accept the terms specified in this agreement. I am over 18 or the legal guardian of the participant above and I accept the terms of the waiver.

Printed Name*

Signature*

Signatory's Birth Date*

Date