Texas Youth Registration Form
Which school does your child attend? (AISD, JISD, BISD, Homeschool, Private, etc)
How did you hear about youth camp? (school, church, business flyer, social media, etc)
Are you coming with a youth group or church? (if yes, please list the name & phone number of your youth pastor)
Street Address Line 2
State / Province
Postal / Zip Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Cocos (Keeling) Islands
Democratic Republic of the Congo
Turkish Republic of Northern Cyprus
Papua New Guinea
Republic of the Congo
Saint Kitts and Nevis
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
Tristan da Cunha
Turks and Caicos Islands
United Arab Emirates
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
I would like to sign up for the following Youth Camps
Youth Camp in the City, Teen Day Camp (8am - 4pm) Texas Youth Convention Mon July 16th - Fri July 20th [ages 12yrs - 18yrs] Cost is $FREE - located at The Johnson County Pioneers and Old Settlers Reunion Building 111 Reunion Drive Alvarado, TX 76009.
Parental Consent (Complete if applicant is under 18yrs)
I give consent for my child mentioned above to participate in the above activities, and I execute the above liability release on their behalf.
I acknowledge that at least one CPR/First Aid/AED certified volunteer will be present during the week to assist as needed.
I give consent for my child to receive Tylenol if needed
I give permission for my child to receive first aid treatment if injured during recreational activities if needed.
I give permission for my child to receive medical care treatment in the event of an emergency if needed.
Liability and Parent Release
In consideration of the acceptance of my registration for the above program, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or other which may hereafter occur to me or my child as a result of participation in events. This release is intended to discharge in advance CKM International Church of Faith and Johnson County Pioneer & Settlers Reunion, its officials, officers, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees.
I hereby authorize CKM International Church of Faith to publish the photographs taken of me and/or the undersigned minor children, and our names, for use in the church website and for display in its facilities. I release CKM International Church of Faith from any expectation of confidentiality for the undersigned minor children and myself and attest that I am the parent or legal guardian of the children listed below and that I have the authority to authorize CKM International Church of Faith to use their photographs and names. I acknowledge that since participation in publications and websites produced by CKM International Church of Faith is voluntary, neither the minor children nor I will receive financial compensation. I further agree that participation in any publication and website produced by CKM International Church of Faith confers no rights of ownership whatsoever. I release CKM International Church of Faith, its contractors, volunteers and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned minor children including but not limited to: photographs, videos, publications and names.
Terms & Conditions
I have read and understood the foregoing registration liability release and parental consent form, and agree to all of its terms and conditions.
Student Full Name
Parent Full Name
Is you child taking any prescription medications? If yes, please list them below
All medications must have correct prescription label to be brought on the trip.
Should be Empty: