Adventure Break Camp Registration

River of Life Adventure Break Camp

Grades Pre-K thru 5th
Pre-K through 5th grade

June 12th through the 16th, 2023.

Program runs from 9:00 am to 12:00 pm.
REGISTRATION AND MEDICAL RELEASE MUST BE COMPLETED BY PARENT/GUARDIAN PLEASE PRINT
Student Information

First NameLast Name
Birth Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Last Grade Completed
Current School
Gender
Parent/Guardian

First NameLast Name
Email
example@example.com
Day Time Phone Number

Area CodePhone Number
Relationship to student
Emergency Contact OTHER THAN parent

First NameLast Name
Day Time Phone Number

Area CodePhone Number
Does your child have any of the following?

Activity restrictionsMedical conditionsFood AllergiesMedication requirements during camp
If yes, please explain.
Consent and Release from Liability

**I grant permission to Holy Trinity Lutheran Church and its agents and employees the unrestricted right to reproduce the photographs and/or video images taken of my child, for the purpose of publication, promotion, or advertising, in any manner or in any medium. I hereby release Holy Trinity Lutheran Church and its legal representatives for all claims and liability relating to said images or video.

I understand that participation in this event is not without risk to my child because of the group nature of the activity/event and unpredictable behavior of any group, even when managed with the greatest amount of care.

I understand that all reasonable safety precautions will be taken at all times by Holy Trinity Lutheran Church and its agents during events/activities. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Holy Trinity Lutheran Church, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by my child.

In addition, this health information is correct, as far as I know and the person named herein has my permission to engage in all prescribed activities except as noted by me. I hereby give permission to the physician selected by Holy Trinity Lutheran Church to hospitalize, secure medical treatment, and/or order and injection, anesthesia, or surgery for my child as deemed necessary.

Participation Agreement

We have read, understand and agree to abide by all rules and restrictions of Adventure Break Camp. We also understand that failure to do so can result in dismissal from the program.
*I DO grant permission to Holy Trinity Lutheran Church and its agents and employees the unrestricted right to reproduce the photographs and/or video images taken of my child, for the purpose of publication, promotion, or advertising, in any manner or in any medium.
Parent/Guardians Signature
**I DO NOT grant permission to Holy Trinity Lutheran Church and its agents and employees the unrestricted right to reproduce the photographs and/or video images taken of my child, for the purpose of publication, promotion, or advertising, in any manner or in any medium.
Parent/Guardians Signature
By typing my name below, I am agreeing to the above Consent and Release from Liability and Participation Agreement.
Parent/Guardians Signature
Should be Empty:

River of Life Adventure Break Camp

REGISTRATION AND MEDICAL RELEASE MUST BE COMPLETED BY PARENT/GUARDIAN PLEASE PRINT