Halifax Christian Academy Day Camp Registration Form

Halifax Christian Academy Day Camp Registration
For families with more than one child attending, please fill out a form for each child.
Student Information
Student's Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Gender

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent/Guardian Information
Name

First NameLast Name
Home Number

Area CodePhone Number
Cell Number

Area CodePhone Number
E-mail
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number

Area CodePhone Number
Alt. Phone Number

Area CodePhone Number
Does the student have any allergies, chronic illness, or medical conditions? If yes, please describe.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Halifax Christian Academy during the day camp. In exchange for the acceptance of said child’s candidacy by Halifax Christian Academy, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Halifax Christian Academy and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of participating in the various day camp activities.In case of injury to said child, I hereby waive all claims against Halifax Christian Academy including all teachers and affiliates, all participants, and, if applicable, owners and lessors of premises used to conduct the event.
Medical Release and Authorization

As Parent and/or Guardian of the named student, 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. I understand that every attempt will be made by Halifax Christian Academy to contact me in the most expeditious way possible. Permission is also granted to the Halifax Christian Academy and its affiliates including directors, teachers, and other staff members to provide needed emergency treatment. 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.
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Halifax Christian Academy Day Camp Registration

For families with more than one child attending, please fill out a form for each child.