Junior Camp Registration

Junior Camp Registration

Please submit one (1) registration per camper.
Parental Contact Information
Parent's Name *

First Name Last Name
Parent's Email *
Parent's Phone # *

Area Code Phone Number

Parent's Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Camper Information
Camper Name *

First Name Last Name
Camper Gender *

Male Female
Camper Grade *
Photos or videos of my child can be used for promotional purposes without remuneration.

Yes No
Special Instructions

Waiver of Liability

This medical release will cover participation at the Jordan YMCA Pool on Tuesday, June 25, between 10AM and 4PM.

This permission includes church/camp transportation to and from the event and during attendance at the event. I assume full responsibility for my son/daughter while participating in this activity and agree that he/she be in submission to those in authority.

As a parent or guardian, I do, herewith, authorize the treatment by a qualified and licensed medical doctor of the registered camper, in the event a medical emergency which, in the opinion of the attending physician, may endanger his or her life, cause disfigurement, physical impairment or undue discomfort if delayed. This authorization is granted only after a reasonable effort has been made to reach me.
Waiver of Liability Signature *

Clear

Payment Information
Total Cost
Paying with cash/check *

Yes No
Paying online with credit/debit *

Yes No
Payment Method *

Cash/Check Online with Credit/Debit Card
PayPal Charge

JBC Registration $ 60.00

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