Summer Camp Registration

Summer Camp Registration

Fill out the form for each child individually

Camps*

Credit Card

First Name

Last Name

Credit Card Number

Security Code

Expiration Month

Expiration Year

Billing Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Parent's Name*

First NameLast Name
Parent's E-mail*
example@example.com
Parent's Phone Number *
Please enter a v.alid phone number.Format: (000) 000-0000.
Child's Name*

First NameLast Name
Child's Gender*
Child's Date of Birth *

MonthDayYear
Date
Please list allergies, medications, dietary restrictions, health problems or any other special considerations:*
The following people have my permission to pick up my student:
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Name*

Phone NumberLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Medical Information
Preferred Physician *
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
MEDICAL RELEASE

In the event of a medical emergency, I authorize the personnel of Panola College to seek appropriate medical attention for my child.

RELEASE & WAIVER OF LIABILITY

The undersigned hereby acknowledges that participation in this camp and related activities involves a possible risk of physical injury. The undersigned on behalf of the registrant, hereby assumes all such risk and does hereby release and forever discharge the camp and all the employees and agents thereof from any and all liability of whatever kind or nature, rising from and by reason of any and all known and unknown, foreseen and unforeseen, bodily injury and personal injuries, damage to property, and the consequences thereof, resulting from the registrants participation in or involvement with this camp, including any failure of equipment or defect in the premises. I hereby state that I am the legal guardian of said registrant.

MEDIA RELEASE

I hereby authorize Panola College to photograph my child/children and any subject matter owned by me or my child, in still picture and motion picture form, and to record my child’s voice, or to cause such photographs and pictures and recording to be made. I hereby consent to the exhibition of such photographs and pictures and the use of my child’s name and voice by you, the world, whether such exhibition and use are sponsored or not. I also consent to the use of such photographs, the right to use my child’s name, voice and photographs and pictures in advertising and in publicity in connection with a subsequent exhibition, and in the exhibition itself. I hereby release you and all other parties from any and all liability, claims or causes of action, arising out of, or created by, the use of my child’s photograph or photographs, picture or pictures, and name and voice, as set forth above. This authorization, consent and release shall apply to all photographs, pictures and recordings of the above-signed, made with the knowledge and acquiescence of the above-signed, from the date hereof until the above-signed shall give you written notice that this authorization, consent and release in no longer effective. This agreement shall be binding on me, my heirs, administrators and executors, and shall inure to the benefit of you, your successors, assigns or licensees.
I have read and agree to the releases above:*
Please verify that you are human*
Should be Empty:

Summer Camp Registration

The following people have my permission to pick up my student:

Medical Information

MEDICAL RELEASE

RELEASE & WAIVER OF LIABILITY

MEDIA RELEASE