Living River Summer Camp Registration

Living River April, 11-13 2025 You & Me Retreat Registration

Please register all adults and children who are attending as a part of your "family group" together. There is no way for adults to register themselves unattached from the children they're attending with. Every child and adult attending the You & Me Retreat will be considered a "camper" for the purposes of the form. That means you too, parent, grandparent, or friend! Email office@livingriver.org with any questions.
Your Name*

First NameLast Name
Your Email*
example@example.com
How many campers (adult and child) are you registering?*
- Child Camper Personal Information
- Camper's Legal Name*
  
  First NameLast Name
- Name Camper Prefers to be Called*
- Camper Birth Date*
  
  MonthDayYear
- MaleFemale
- Grade (rising)*
  Grade for the next school year.
- T-shirt Size*
- Church*
- Church, if -Not Listed-
- YesNo
- If yes, did anyone invite you to Living River?
- Did you invite anyone to Summer Camp who you believe will register and attend for the "invite a friend discount?"
  List all names if you invited more than one!
- Cabinmate Request (We will attempt to honor one request.)
- Please share any information (emotional or physical) which might help the staff understand and serve your camper.
- Does your camper have any accommodations or an educational plan at school that would be helpful for camp staff to utilize?
- Parent/Guardian Name*
  
  First NameLast Name
- Parent/Guardian Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Parent/Guardian Phone Number*
  
  Area CodePhone Number
- Parent/Guardian E-mail*
- Emergency Contact Information
  
  Please choose someone who isn't attending You & Me.
- Emergency Contact's Name*
  
  First NameLast Name
- Relationship*
- Phone Number*
  
  Area CodePhone Number
- Alt. Phone Number*
  
  Area CodePhone Number
- Medical Information
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please list each medication in this way- medication name, dosage, medication instructions. *If your child requires an EpiPen, please provide 2 non-expired EpiPens, one for your child to carry with them and one to keep in the cabin.*
- Check all over-the-counter medications that our healthcare provider may give this camper as needed:*
- Date of last tetanus shot*
  
  MonthDayYear
  Date
- YesNo
- If no, which vaccine(s) is this camper on an different schedule with or has not had?*
- Who is the child's primary health care provider? (In case of emergency)*
- Provider's Phone Number*
  
  Area CodePhone Number
- Additional Camper?
- YesNo
- Child Camper No. 2 Personal Information
- Camper's Legal Name:*
  
  First NameLast Name
- Name Camper Prefers to be Called:*
- Camper Birth Date*
  
  MonthDayYear
- MaleFemale
- T-shirt Size*
- Grade (rising)*
  Grade for the next school year.
- Church*
- Church, if -Not Listed-
- YesNo
- If yes, did anyone invite you to Living River?
- Did you invite anyone to Summer Camp who you believe will register and attend for the "invite a friend discount?"
  List all names if you invited more than one!
- Cabinmate Request: (We will attempt to honor one request.)
- Please share any information (emotional or physical) which might help the staff understand and serve your camper.
- Does your camper have any accommodations or an educational plan at school that would be helpful for camp staff to utilize?
- Parent/Guardian Name*
  
  First NameLast Name
- Parent/Guardian Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Parent/Guardian Phone Number*
  
  Area CodePhone Number
- Parent/Guardian E-mail*
  example@example.com
- Child Camper No. 2 Emergency Contact Information
  
  Please choose someone who isn't attending You & Me.
- Emergency Contact's Name*
  
  First NameLast Name
- Relationship*
- Phone Number*
  
  Area CodePhone Number
- Alt. Phone Number*
  
  Area CodePhone Number
- Child Camper No. 2 Medical Information
  
  Please answer all questions completely.
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please list each medication in this way- medication name, dosage, medication instructions. *If your child requires an EpiPen, please provide 2 non-expired EpiPens, one for your child to carry with them and one to keep in the cabin.*
- Check all over-the-counter medications that our healthcare provider may give this camper as needed:*
- Date of last tetanus shot*
  
  MonthDayYear
  Date
- YesNo
- If no, which vaccine(s) is this camper on an different schedule with or has not had?*
- Who is the child's primary health care provider? (In case of emergency)*
- Provider's Phone Number:*
- Additional Camper?
- YesNo
- Child Camper No. 3 Personal Information
- Camper's Legal Name:*
  
  First NameLast Name
- Name Camper Prefers to be Called:*
- Camper Birth Date*
  
  MonthDayYear
- MaleFemale
- Grade (rising)*
  Grade for the next school year.
- T-shirt Size*
- Church*
- Church, if -Not Listed-
- YesNo
- If yes, did anyone invite you to Living River?
- Did you invite anyone to Summer Camp who you believe will register and attend for the "invite a friend discount?"
  List all names if you invited more than one!
- Cabinmate Request: (We will attempt to honor one request.)
- Please share any information (emotional or physical) which might help the staff understand and serve your camper.
- Does your camper have any accommodations or an educational plan at school that would be helpful for camp staff to utilize?
- Parent/Guardian Name*
  
  First NameLast Name
- Parent/Guardian Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Parent/Guardian Phone Number*
  
  Area CodePhone Number
- Parent/Guardian E-mail*
  example@example.com
- Child Camper No. 3 Emergency Contact Information
  
  Please choose someone who isn't attending You & Me.
- Emergency Contact's Name*
  
  First NameLast Name
- Relationship*
- Phone Number*
  
  Area CodePhone Number
- Alt. Phone Number*
  
  Area CodePhone Number
- Child Camper No. 3 Medical Information
  
  Please answer all questions completely.
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please list each medication in this way- medication name, dosage, medication instructions. *If your child requires an EpiPen, please provide 2 non-expired EpiPens, one for your child to carry with them and one to keep in the cabin.*
- Check all over-the-counter medications that our healthcare provider may give this camper as needed:*
- Date of last tetanus shot*
  
  MonthDayYear
  Date
- YesNo
- If no, which vaccine(s) is this camper on an different schedule with or has not had?*
- Who is this camper's primary health care provider? (In case of emergency)*
- Provider's Phone Number:*
- Additional Camper?
- YesNo
- Child Camper No. 4 Camper Personal Information
- Camper's Legal Name:*
  
  First NameLast Name
- Name Camper Prefers to be Called:*
- Camper Birth Date*
  
  MonthDayYear
- MaleFemale
- T-shirt Size*
- Grade (rising)*
  Grade for the next school year.
- Church*
- Church, if -Not Listed-
- YesNo
- If yes, did anyone invite you to Living River?
- Did you invite anyone to Summer Camp who you believe will register and attend for the "invite a friend discount?"
  List all names if you invited more than one!
- Cabinmate Request: (We will attempt to honor one request.)
- Please share any information (emotional or physical) which might help the staff understand and serve your camper.
- Does your camper have any accommodations or an educational plan at school that would be helpful for camp staff to utilize?
- Parent/Guardian Name*
  
  First NameLast Name
- Parent/Guardian Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Parent/Guardian Phone Number*
  
  Area CodePhone Number
- Parent/Guardian E-mail*
  example@example.com
- Child Camper No. 4 Emergency Contact Information
  
  Please choose someone who isn't attending You & Me.
- Emergency Contact's Name*
  
  First NameLast Name
- Relationship*
- Phone Number*
  
  Area CodePhone Number
- Alt. Phone Number*
  
  Area CodePhone Number
- Child Camper No. 4 Medical Information
  
  Please answer all questions completely.
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please list each medication in this way- medication name, dosage, medication instructions. *If your child requires an EpiPen, please provide 2 non-expired EpiPens, one for your child to carry with them and one to keep in the cabin.*
- Check all over-the-counter medications that our healthcare provider may give this camper as needed:*
- Date of last tetanus shot*
  
  MonthDayYear
  Date
- YesNo
- If no, which vaccine(s) is this camper on an different schedule with or has not had?*
- Who is this camper's primary health care provider? (In case of emergency)*
- Provider's Phone Number:*
- Additional Camper?
- YesNo
- Child Camper No. 5 Camper Personal Information
- Camper's Legal Name:*
  
  First NameLast Name
- Name Camper Prefers to be Called:*
- Camper Birth Date*
  
  MonthDayYear
- MaleFemale
- T-shirt Size*
- Grade (rising)*
  Grade for the next school year.
- Church*
- Church, if -Not Listed-
- YesNo
- If yes, did anyone invite you to Living River?
- Did you invite anyone to Summer Camp who you believe will register and attend for the "invite a friend discount?"
  List all names if you invited more than one!
- Cabinmate Request: (We will attempt to honor one request.)
- Please share any information (emotional or physical) which might help the staff understand and serve your camper.
- Does your camper have any accommodations or an educational plan at school that would be helpful for camp staff to utilize?
- Parent/Guardian Name*
  
  First NameLast Name
- Parent/Guardian Address*
  
  Street Address
  
  Street Address Line 2
  
  CityState
  
  Zip Code
- Parent/Guardian Phone Number*
  
  Area CodePhone Number
- Parent/Guardian E-mail*
  example@example.com
- Child Camper No. 5 Emergency Contact Information
  
  Please choose someone who isn't attending You & Me.
- Emergency Contact's Name*
  
  First NameLast Name
- Relationship*
- Phone Number*
  
  Area CodePhone Number
- Alt. Phone Number*
  
  Area CodePhone Number
- Child Camper No. 5 Medical Information
  
  Please answer all questions completely.
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please list each medication in this way- medication name, dosage, medication instructions. *If your child requires an EpiPen, please provide 2 non-expired EpiPens, one for your child to carry with them and one to keep in the cabin.*
- Check all over-the-counter medications that our healthcare provider may give this camper as needed:*
- Date of last tetanus shot*
  
  MonthDayYear
  Date
- YesNo
- If no, which vaccine(s) is this camper on an different schedule with or has not had?*
- Who is this camper's primary health care provider? (In case of emergency)*
- Provider's Phone Number:*
- Adult Camper Personal Information
- Camper's Legal Name:*
  
  First NameLast Name
- Name Camper Prefers to be Called:*
- Camper Birth Date*
  
  MonthDayYear
- MaleFemale
- T-shirt Size*
- Church*
- Church, if -Not Listed-
- YesNo
- If yes, did anyone invite you to Living River?
- Did you invite anyone to Summer Camp who you believe will register and attend for the "invite a friend discount?"
  List all names if you invited more than one!
- Cabinmate Request: (We will attempt to honor one request.)
- Please share any information (emotional or physical) which might help the staff understand and serve this camper.
- Adult Camper Emergency Contact Information
  
  Please choose someone who isn't attending You & Me.
- Emergency Contact's Name*
  
  First NameLast Name
- Relationship*
- Phone Number*
  
  Area CodePhone Number
- Alt. Phone Number*
  
  Area CodePhone Number
- Adult Camper Medical Information
  
  Please answer all questions completely.
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please list each medication in this way- medication name, dosage, medication instructions. *If your child requires an EpiPen, please provide 2 non-expired EpiPens, one for your child to carry with them and one to keep in the cabin.*
- Check all over-the-counter medications that our healthcare provider may give this camper as needed:*
- Date of last tetanus shot*
  
  MonthDayYear
  Date
- Who is your primary health care provider? (In case of emergency)*
- Provider's Phone Number:*
- Additional Camper?
- YesNo
- Adult Camper No. 2 Personal Information
- Camper's Legal Name:*
  
  First NameLast Name
- Name Camper Prefers to be Called:*
- Camper Birth Date*
  
  MonthDayYear
- MaleFemale
- T-shirt Size*
- Church*
- Church, if -Not Listed-
- YesNo
- If yes, did anyone invite you to Living River?
- Did you invite anyone to Summer Camp who you believe will register and attend for the "invite a friend discount?"
  List all names if you invited more than one!
- Cabinmate Request: (We will attempt to honor one request.)
- Please share any information (emotional or physical) which might help the staff understand and serve this camper.
- Adult Camper No. 2 Emergency Contact Information
  
  Please choose someone who isn't attending You & Me.
- Emergency Contact's Name*
  
  First NameLast Name
- Relationship*
- Phone Number*
  
  Area CodePhone Number
- Alt. Phone Number*
  
  Area CodePhone Number
- Adult Camper No. 2 Medical Information
  
  Please answer all questions completely.
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please list each medication in this way- medication name, dosage, medication instructions. *If your child requires an EpiPen, please provide 2 non-expired EpiPens, one for your child to carry with them and one to keep in the cabin.*
- Check all over-the-counter medications that our healthcare provider may give this camper as needed:*
- Date of last tetanus shot*
  
  MonthDayYear
  Date
- Who is your primary health care provider? (In case of emergency)*
- Provider's Phone Number:*
- Additional Camper?
- YesNo
- Adult Camper No. 3 Personal Information
- Camper's Legal Name:*
  
  First NameLast Name
- Name Camper Prefers to be Called:*
- Camper Birth Date*
  
  MonthDayYear
- MaleFemale
- T-shirt Size*
- Church*
- Church, if -Not Listed-
- YesNo
- If yes, did anyone invite you to Living River?
- Did you invite anyone to Summer Camp who you believe will register and attend for the "invite a friend discount?"
  List all names if you invited more than one!
- Cabinmate Request: (We will attempt to honor one request.)
- Please share any information (emotional or physical) which might help the staff understand and serve this camper.
- Adult Camper No. 3 Emergency Contact Information
  
  Please choose someone who isn't attending You & Me.
- Emergency Contact's Name*
  
  First NameLast Name
- Relationship*
- Phone Number*
  
  Area CodePhone Number
- Alt. Phone Number*
  
  Area CodePhone Number
- Adult Camper No. 3 Medical Information
  
  Please answer all questions completely.
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please list each medication in this way- medication name, dosage, medication instructions. *If your child requires an EpiPen, please provide 2 non-expired EpiPens, one for your child to carry with them and one to keep in the cabin.*
- Check all over-the-counter medications that our healthcare provider may give this camper as needed:*
- Date of last tetanus shot*
  
  MonthDayYear
  Date
- Who is your primary health care provider? (In case of emergency)*
- Provider's Phone Number:*
- Additional Camper?
- YesNo
- Adult Camper No. 4 Personal Information
- Camper's Legal Name:*
  
  First NameLast Name
- Name Camper Prefers to be Called:*
- Camper Birth Date*
  
  MonthDayYear
- MaleFemale
- T-shirt Size*
- Church*
- Church, if -Not Listed-
- YesNo
- If yes, did anyone invite you to Living River?
- Did you invite anyone to Summer Camp who you believe will register and attend for the "invite a friend discount?"
  List all names if you invited more than one!
- Cabinmate Request: (We will attempt to honor one request.)
- Please share any information (emotional or physical) which might help the staff understand and serve this camper.
- Adult Camper No. 4 Emergency Contact Information
  
  Please choose someone who isn't attending You & Me.
- Emergency Contact's Name*
  
  First NameLast Name
- Relationship*
- Phone Number*
  
  Area CodePhone Number
- Alt. Phone Number*
  
  Area CodePhone Number
- Adult Camper No. 4 Medical Information
  
  Please answer all questions completely.
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please describe.*
- YesNo
- If yes, please list each medication in this way- medication name, dosage, medication instructions. *If your child requires an EpiPen, please provide 2 non-expired EpiPens, one for your child to carry with them and one to keep in the cabin.*
- Check all over-the-counter medications that our healthcare provider may give this camper as needed:*
- Who is your primary health care provider? (In case of emergency)*
- Provider's Phone Number:*

Insurance Information
Medical Insurance Company*
Contract Holder Name*
Group #*
Contract #*
Upload a copy or take a picture of your insurance card below:
Upload a picture of your insurance card -OR-

Browse Files

Cancelof
Take a photo of the front of your card.
If any camper in your group is on a different insurance, upload a copy or take a picture of the second below. If there is an additional isurance beyond these two or you have any questions, please email office@livingriver.org.
Upload a picture of your group's additional insurance card -OR-

Browse Files

Cancelof
Take a photo of the front of the card.

Payment and Consent
Scholarship Assistance- If you need financial assistance, please select "pay by check," finish and submit this form, and then email office@livingriver.org to alert Living River of your need. Living River has scholarship funds available. Anyone who needs it will qualify for. We ask that, if able, each family unit pay a minimum of $25 per camper. After filling out the scholarship form sent by Living River, the additional amount can be paid by check or invoiced through PayPal. Please also reach out with any questions! We do not want finances to be an obstacle for any camper or family.
Pay my full amount online now.Pay by check (mailed to Living River, 2000 Living River Pkwy Montevallo, AL 35115, or brought to the retreat itself)..Bill me my total after the retreat.Bill my church.
I understand that I am responsible for the full amount if Living River does not receive a scholarship request or funds from my home church.
Total:
Total to Pay through PayPal:

prevnext( X )
USDRegistration Total
Photos/Publicity

I understand that photos of my child or me may be used by Living River for publicity purposes in print or on social media. Names will not be printed. If I do not wish photographs of my child to be used in this capacity I will notify staff, in writing, before the beginning of the camp session.
Informed Consent and Acknowledgement

I, the undersigned, being the parent or legal guardian of the child named above permit my child to participate in all camp activities and I will hold Living River harmless in case of injury or illness. I understand that I will be notified in case of medical or surgical emergency involving my child. However, in the event that I or persons I have designated cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I understand Living River will not be responsible for medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. I will notify the camp director of any problems or restrictions which would affect participation in normal camp activities prior to the camp period. I also understand that the adult supervisors reserve the right to restrict my child from any activity that they do not feel is within the physical capabilities of my child. I agree to abide by the decisions of the director(s) in the case of sending the camper home due to illness or fails to abide by the camp rules.
Confirmation

Your electronic signature below is equally as binding as an original, manual signature. Your signature applies the above consent forms to every camper you have registered.
Signature*

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Living River April, 11-13 2025 You & Me Retreat Registration

Child Camper Personal Information

Emergency Contact Information

Medical Information

Additional Camper?

Child Camper No. 2 Personal Information

Child Camper No. 2 Emergency Contact Information

Child Camper No. 2 Medical Information

Additional Camper?

Child Camper No. 3 Personal Information

Child Camper No. 3 Emergency Contact Information

Child Camper No. 3 Medical Information

Additional Camper?

Child Camper No. 4 Camper Personal Information

Child Camper No. 4 Emergency Contact Information

Child Camper No. 4 Medical Information

Additional Camper?

Child Camper No. 5 Camper Personal Information

Child Camper No. 5 Emergency Contact Information

Child Camper No. 5 Medical Information

Adult Camper Personal Information

Adult Camper Emergency Contact Information

Adult Camper Medical Information

Additional Camper?

Adult Camper No. 2 Personal Information

Adult Camper No. 2 Emergency Contact Information

Adult Camper No. 2 Medical Information

Additional Camper?

Adult Camper No. 3 Personal Information

Adult Camper No. 3 Emergency Contact Information

Adult Camper No. 3 Medical Information

Additional Camper?

Adult Camper No. 4 Personal Information

Adult Camper No. 4 Emergency Contact Information

Adult Camper No. 4 Medical Information

Insurance Information

Payment and Consent