Summer Camp Detailed Registration Form

Warren Congregational Church
Vacation Bible School
Child’s Name

First NameLast Name
Birth Date

MonthDayYear
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Emergency Information
Relationship
Emergency Contact's Name

First NameLast Name
Phone Number
Alt. Phone Number
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Do you give permission for your camper to be photographed during Vacation Bible School for any legal use such as publicity, copyright purposes, illustration, advertising, and web content?

YesNo
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Warren Congregational Church during Vacation Bible School. In exchange for the acceptance of said child’s candidacy by Warren Congregational Church. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Warren Congregational Church and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from Vacation Bible School.

In case of injury to said child, I hereby waive all claims against Warren Congregational Church including all coaches and affiliates, all participants, staff, and volunteers
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature

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Warren Congregational Church

Vacation Bible School