IP Deaf Family Retreat Registration Form

Isaiah's Place Family Registration

for overnight stays
FAMILY INFORMATION:
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Child Name

First NameLast Name
Birth Date

MonthDayYear
Grade
Child Name

First NameLast Name
Birth Date

MonthDayYear
Grade
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Phone Number/text*

Area CodePhone Number
E-mail*
example@example.com
I agree to a background check*

YesNo
Birthdate*
I will take the Child Protection Exam for IP online.*

YesNo
Parent/Guardian Name

First NameLast Name
Phone Number/text

Area CodePhone Number
E-mail
I agree to a background check

YesNo
Birthdate
I will take the Child Protection Exam for IP online.

YesNo
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
M1EDICAL INFORMATION
Please list Family Food Allergies*
Medical Concerns
Date Arriving*

MonthDayYear
Date
Date Leaving*

MonthDayYear
Date
Release and Reproduced Images:

RELEASE: In consideration of, and as part payment for the right to participate in Activities and the services and food arranged by CAMP, Applicant: (1) fully releases CAMP from current or future liability from negligence, gross negligence, or intentional tort by any person, (2) assumes all Risks and Dangers, whether or not that risk is foreseeable, and (3) will indemnify and hold CAMP harmless from any and all claims, liability, actions, causes of action, debts, claims and demands of every kind and nature whatsoever, for personal injury, property damage or loss, psychological injury or emotional distress, or medical expenses of any kind and attorney’s fees and costs of court filed by Applicant, or by other parties against CAMP, connected with Applicant’s program or participation in any activities at CAMP or arranged by the CAMP. REPRODUCED IMAGES I authorize and release the use of Applicant’s image to be reproduced in any form including, but not limited to, newspapers, photographs, magazines, and internet websites, to CAMP for any purpose of CAMP
Sign and Type your name in agreement with the above release.*
Name and Date
Cost $25 per family per night. Cost $10 per person per night.

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Isaiah's Place Family Registration

FAMILY INFORMATION:

PARENT/GUARDIAN INFORMATION:

M1EDICAL INFORMATION

Release and Reproduced Images: