Clone of Summer Camp Detailed Registration Form

Camper Information
Camper's Name

First NameLast Name
Nickname
What type of attendee: After June 8th, camp registration will increase to $150
Birth Date

MonthDayYear
Age
Gender
T-Shirt Size
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name

First NameLast Name
Home Number
Format: (000) 000-0000.
Cell Number
Format: (000) 000-0000.
E-mail
example@example.com
Church Information
Home Church
Pastor's Name
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Format: (000) 000-0000.
Alt. Phone Number
Format: (000) 000-0000.
Does the Camper have any allergies, chronic illness, or medical conditions? If yes, please describe.

Waiver's and Rleases

Parent or Guardian must sign unless camper is 18 years of age or older
ACCIDENT WAIVER AND RELEASE OF LIABILITY
I hereby assume all of the risks of participating in any/all activities associated with this event(s), including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons.

I acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders, sponsors, and organizers of the activity in which I may participate and that it will govern my actions and responsibilities at said activity. In consideration of my application and permitting me to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:

(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from this activity,

THE FOLLOWING ENTITIES OR PERSONS: Camp Tuscoba staff, The Alabama District volunteers, representatives, and the activity holders.

(B) INDEMNIFY, HOLD HARMLESS AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise.

I acknowledge that Camp Tuscoba staff, The Alabama District volunteers, and representatives, are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf.

I acknowledge that the risks include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not limited to, Camp Tuscoba. Participants, and volunteers. These risks are not only inherent to participants but are also present for volunteers.

I hereby consent to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity.

I understand while participating in this activity, I may be photographed. I agree to allow the Alabama District to use my photo, video, or film likeness for any legitimate purpose for advertising next year’s camp.

The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
Parent/Guardian Signature
Date

MonthDayYear
Date
Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named camper. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Alabama District ALJC, and its affiliates including Directors, Staff, and Camp Counselors to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered camp dates.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
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.
Parent/Guardian Signature
Date

MonthDayYear
Date

Payment & Remittance
Please make checks out to: Alabama District ALJC

All registration forms MUST BE SUBMITTED ON OR BEFORE June 31ST

If there is a late camper attending, you must clear it first with Bro TC Barnett or Sis Amanda Simmons!
Payment Method
Should be Empty:

Camper Information

Church Information

Waiver's and Rleases

Payment & Remittance