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
T-Shirt Size:
*
Please Select
S
M
L
XL
2XL
3XL
Bunk Mate Request:
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
*
Does the child have any medical conditions?
*
Yes
No
Please give details
Does the child have any allergies to food or medications?
*
Yes
No
Will your child need any medications during the trip? If so, please list below.
*
If you have insurance, please upload a photo of your Childs insurance card:
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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, the undersigned parent/legal guardian of the above-named student, give permission for my child to participate in SURGE River Youth Summer Camp and events hosted by The River of Columbus Church. I understand that reasonable precautions and adult supervision will be provided, but participation in these activities involves certain inherent risks, including, but not limited to, travel in church vans or other vehicles, swimming, recreational games, and other physical activities. I acknowledge and accept these risks on behalf of my child.I hereby release and hold harmless The River of Columbus Church, its staff, volunteers, agents, and representatives from any and all liability, claims, demands, or actions, including injury, illness, or property damage, arising out of or related to participation in any youth activities, including transportation to and from events.
In the event of a medical emergency, I authorize The River of Columbus Church leaders and volunteers to obtain medical treatment for my child. I agree to be financially responsible for any costs incurred as a result of such treatment.
Date
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Month
-
Day
Year
Date
Signature
*
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