Camper Registration Form

1
Parent/Guardian Name* This field is required.Please give the full name of the parent/guardian who is filling out this form for campers.
First Name
Last Name
2
Relationship to the Camper
3
Parent or Legal Guardian Phone Number* This field is required.
Please enter a valid phone number.
4
Email* This field is required.
example@example.com
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Emergency Contact
First Name
Last Name
7
Emergency Contact's Relation To The Camper
8
Emergency Contact Phone Number
Please enter a valid phone number.
9
Church Name & City (if attending with one)
Huge
Large
Normal
Small
Ok
Ok
10
Camper Name* This field is required.
First Name
Last Name
11
Camper's Date of Birth* This field is required.
Date
Month
Day
Year
12
Which Week of Camp is this camper registering for?
Junior Week 1 - Bob Mann (June 30 - July 4)
Teen Week - Dave Young (July 7 - 11)
Junior Week 2 - Steve DeSantis (July 14 - 18) - Almost Full*
Deaf Week - Randy Dignan (July 21-25)
13
Please select the camper's gender* This field is required.
Male
Female
14
Grade entering next school year* This field is required.
15
Insurance Provider & Policy #
Huge
Large
Normal
Small
Ok
Ok
16
Physician Name & Phone #
17
Date of Last Tetanus Shot (If none - please type "none")This is just for our camper medical records and not a pre-requisite for attending camp.
18
Immunizations up to date?This is just for our camper medical records and not a pre-requisite for attending camp.
YESNO
19
Has this camper been diagnosed with any of the following?I understand that all medications, including EpiPens, inhalers, or any other prescription or over-the-counter medication, must be in their original labeled containers and must be turned in to the designated camp medical staff upon arrival. Medications must be prescribed specifically to the camper who needs them and clearly labeled with their name. Campers are not permitted to share or use another person’s medication under any circumstance. If my child has been diagnosed with ADHD or a similar condition, I understand that a note may be required from a doctor, teacher, or another adult who can reasonably attest to the camper’s ability to function well in an organized, group setting for the duration of the camp week.
ADHD
Severe Allergies
Seasonal Allergies
Asthma
Epilepsy
Diabetes
Lactose Intolerance
None
Other
20
Please list all current medications, dosage, and schedule.All medications must be in their original packaging with the camper's name visible and
Huge
Large
Normal
Small
Ok
Ok
21
I give permission for Camp Liberty staff or volunteers to provide basic first aid and to administer the following over-the-counter medications as needed:Must be selected if you want your child to be able to receive this over the counter medication as needed.
Acetaminophen (Tylenol)
Ibuprofen (Advil/Motrin)
Diphenhydramine (Benadryl)
Antacid (Tums, etc.)
Dramamine (Motion Sickness)
Sunscreen
22
Do You Have Another Camper to Register?
YESNO
23
Camper Name* This field is required.
First Name
Last Name
24
Camper's Date of Birth
Date
Month
Day
Year
25
Which Week of Camp is this camper registering for?
Junior Week 1 - Bob Mann (June 30 - July 4)
Teen Week - Dave Young (July 7 - 11)
Junior Week 2 - Steve DeSantis (July 14 - 18) - Almost Full*
Deaf Week - Randy Dignan (July 21-25)
26
Please select the camper's gender* This field is required.
Male
Female
27
Grade entering next school year
28
Insurance Provider & Policy #
Huge
Large
Normal
Small
Ok
Ok
29
Physician Name & Phone #
30
Date of Last Tetanus Shot (If none - please type "none")This is just for our camper medical records and not a pre-requisite for attending camp.
31
Immunizations up to date?This is just for our camper medical records and not a pre-requisite for attending camp.
YESNO
32
Has this camper been diagnosed with any of the following?I understand that all medications, including EpiPens, inhalers, or any other prescription or over-the-counter medication, must be in their original labeled containers and must be turned in to the designated camp medical staff upon arrival. Medications must be prescribed specifically to the camper who needs them and clearly labeled with their name. Campers are not permitted to share or use another person’s medication under any circumstance. If my child has been diagnosed with ADHD or a similar condition, I understand that a note may be required from a doctor, teacher, or another adult who can reasonably attest to the camper’s ability to function well in an organized, group setting for the duration of the camp week.
ADHD
Severe Allergies
Seasonal Allergies
Asthma
Epilepsy
Diabetes
Lactose Intolerance
None
Other
33
Please list all current medications, dosage, and schedule.All medications must be in their original packaging with the camper's name visible and
Huge
Large
Normal
Small
Ok
Ok
34
I give permission for Camp Liberty staff or volunteers to provide basic first aid and to administer the following over-the-counter medications as needed:Must be selected if you want your child to be able to receive this over the counter medication as needed.
Acetaminophen (Tylenol)
Ibuprofen (Advil/Motrin)
Diphenhydramine (Benadryl)
Antacid (Tums, etc.)
Dramamine (Motion Sickness)
Sunscreen
35
Do You Have Another Camper to Register?
YESNO
36
Camper Name* This field is required.
First Name
Last Name
37
Camper's Date of Birth
Date
Month
Day
Year
38
Which Week of Camp is this camper registering for?
Junior Week 1 - Bob Mann (June 30 - July 4)
Teen Week - Dave Young (July 7 - 11)
Junior Week 2 - Steve DeSantis (July 14 - 18) - Almost Full*
Deaf Week - Randy Dignan (July 21-25)
39
Please select the camper's gender* This field is required.
Male
Female
40
Grade entering next school year
41
Insurance Provider & Policy #
Huge
Large
Normal
Small
Ok
Ok
42
Physician Name & Phone #
43
Date of Last Tetanus Shot (If none - please type "none")This is just for our camper medical records and not a pre-requisite for attending camp.
44
Immunizations up to date?This is just for our camper medical records and not a pre-requisite for attending camp.
YESNO
45
Has this camper been diagnosed with any of the following?I understand that all medications, including EpiPens, inhalers, or any other prescription or over-the-counter medication, must be in their original labeled containers and must be turned in to the designated camp medical staff upon arrival. Medications must be prescribed specifically to the camper who needs them and clearly labeled with their name. Campers are not permitted to share or use another person’s medication under any circumstance. If my child has been diagnosed with ADHD or a similar condition, I understand that a note may be required from a doctor, teacher, or another adult who can reasonably attest to the camper’s ability to function well in an organized, group setting for the duration of the camp week.
ADHD
Severe Allergies
Seasonal Allergies
Asthma
Epilepsy
Diabetes
Lactose Intolerance
None
Other
46
Please list all current medications, dosage, and schedule.All medications must be in their original packaging with the camper's name visible and
Huge
Large
Normal
Small
Ok
Ok
47
I give permission for Camp Liberty staff or volunteers to provide basic first aid and to administer the following over-the-counter medications as needed:* This field is required.Must be selected if you want your child to be able to receive this over the counter medication as needed.
Acetaminophen (Tylenol)
Ibuprofen (Advil/Motrin)
Diphenhydramine (Benadryl)
Antacid (Tums, etc.)
Dramamine (Motion Sickness)
Sunscreen
48
Do You Have Another Camper to Register?* This field is required.
YESNO
49
Camper Name* This field is required.
First Name
Last Name
50
Camper's Date of Birth* This field is required.
Date
Month
Day
Year
51
Which Week of Camp is this camper registering for?
Junior Week 1 - Bob Mann (June 30 - July 4)
Teen Week - Dave Young (July 7 - 11)
Junior Week 2 - Steve DeSantis (July 14 - 18) - Almost Full*
Deaf Week - Randy Dignan (July 21-25)
52
Please select the camper's gender* This field is required.
Male
Female
53
Grade entering next school year
54
Insurance Provider & Policy #
Huge
Large
Normal
Small
Ok
Ok
55
Physician Name & Phone #
56
Date of Last Tetanus Shot (If none - please type "none")This is just for our camper medical records and not a pre-requisite for attending camp.
57
Immunizations up to date?This is just for our camper medical records and not a pre-requisite for attending camp.
YESNO
58
Has this camper been diagnosed with any of the following?I understand that all medications, including EpiPens, inhalers, or any other prescription or over-the-counter medication, must be in their original labeled containers and must be turned in to the designated camp medical staff upon arrival. Medications must be prescribed specifically to the camper who needs them and clearly labeled with their name. Campers are not permitted to share or use another person’s medication under any circumstance. If my child has been diagnosed with ADHD or a similar condition, I understand that a note may be required from a doctor, teacher, or another adult who can reasonably attest to the camper’s ability to function well in an organized, group setting for the duration of the camp week.
ADHD
Severe Allergies
Seasonal Allergies
Asthma
Epilepsy
Diabetes
Lactose Intolerance
None
Other
59
Please list all current medications, dosage, and schedule.All medications must be in their original packaging with the camper's name visible and
Huge
Large
Normal
Small
Ok
Ok
60
I give permission for Camp Liberty staff or volunteers to provide basic first aid and to administer the following over-the-counter medications as needed:Must be selected if you want your child to be able to receive this over the counter medication as needed.
Acetaminophen (Tylenol)
Ibuprofen (Advil/Motrin)
Diphenhydramine (Benadryl)
Antacid (Tums, etc.)
Dramamine (Motion Sickness)
Sunscreen
61
Camp Liberty Waiver, Medical Release, and Photo Release* This field is required.I, the undersigned parent or legal guardian of the camper named in this registration, hereby grant permission for my child to participate in all activities at Camp Liberty, located at 483 F County Road 275, Oakwood, TX 75855. I understand that these activities may include, but are not limited to, water games, hiking, field games, team competitions, archery, axe throwing, slingshots, and use of a .22 rifle range, under the supervision of qualified staff and volunteers. I understand that while every effort will be made to provide a safe and secure environment, participation in camp activities involves inherent risks, including the risk of injury, illness, or accident. I acknowledge and accept these risks and agree to hold Camp Liberty, its staff, volunteers, officers, directors, and property owners harmless from any liability, claim, or cause of action arising out of or related to any injury, illness, accident, or loss incurred by my child during camp. In the event of an emergency, I hereby authorize Camp Liberty staff or volunteers to act on my behalf to obtain emergency medical treatment for my child. I give permission for a licensed physician, emergency medical personnel, or other qualified healthcare provider to administer necessary medical treatment, including hospitalization, anesthesia, surgery, injections, medication, or diagnostic procedures. I understand that reasonable efforts will be made to contact me prior to the initiation of any such treatment, but if I cannot be reached, I consent to the necessary care for the safety and well-being of my child. I understand that I am responsible for all medical costs and expenses incurred as a result of such treatment, including but not limited to physician fees, hospital bills, medications, and ambulance services. I release Camp Liberty and its representatives from financial responsibility for any such care provided. I also authorize Camp Liberty staff to administer basic first aid as needed and to provide any over-the-counter medications that I have approved on the medication section of this registration form. 📸 Photo and Media Release I give permission for photos and videos of my child to be taken during the course of camp and used in Camp Liberty's promotional materials, social media posts, ministry updates, and website. I understand that no identifying personal information will be used or disclosed without additional consent.
YESNO
62
I verify that I have read and understand all of the above information. I certify that I have completed this form accurately and to the best of my knowledge. I understand and agree to the waiver, medical release, and photo release as outlined above.
YESNO
63
Registration PaymentRegistration is due at time of registration.
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