• Shine On Registration Form

  • Child #1 Information

    Please submit one form per camper
  • Sex*
  • Allergies

  • Child #2 Information

    Please submit one form per camper
  • Sex
  • Allergies

  • Child #3 Information

    Please submit one form per camper
  • Sex
  • Allergies

  • PARENT/GUARDIAN INFORMATION

  • Format: (000) 000-0000.

  • Emergency Contact (other than the parent above)

    In the case that we are unable to reach you in an emergency, please provide the name and number of someone we can contact (other than the parent above).
  • Format: (000) 000-0000.

  • Pick-up Person (other than the parent above)

    If someone other than the parent above is picking up the child/children, please provide the name and number of that person
  • Format: (000) 000-0000.

  • Application Consent

  • I understand and acknowledge the following:

    Emergency Contact Information: I have provided accurate emergency contact information, including my contact number, an alternate contact person, and their contact details. In case of any emergency, I authorize the camp staff to contact me or the designated alternate contact.
    Medical Authorization: I , the parent or guardian of the above child/children, in the case of an emergency and City Church Lloyd staff being unable to get ahold/contact parent or guardian, authorize the Ministry of City Church Lloyd to get immediate help from a physician or hospital to provide medical assessment, treatment or procedures for the child/children named above. Until parent/guardian is reached I authorize Ministry of City Church Lloyd to give permissions to physicians or hospital based on their recommendations.
    Photo and Video Release: I , the parent or guardian of above child/ children, grant
    City Church Lloyd my permission to use the photographs for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content.
    Furthermore, I understand that no royalty fee or other compensation shall become payable to me by reason of such use.
    Liability Release: I release City Church Lloyd, its staff, volunteers, and affiliates from any liability for injuries, accidents, or loss of personal property that may occur during any church activities.
    By signing below, I confirm that I have read, understood, and agree to the terms and conditions outlined in this consent form. I hereby give my permission for my child/ward to participate in the Church Camp and engage in all planned activities.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: