Adventure Break Camp Registration

Adventure Break Camp Registration
March 9th thru the 13th.

Doors open at 7:30 am.

Program runs from 8:30 am to 3 pm.

All children must be picked up by 5:00 pm.

The cost is $25 per child for the week.
REGISTRATION AND MEDICAL RELEASE MUST BE COMPLETED BY PARENT/GUARDIAN PLEASE PRINT
Student Information

First Name Last Name
Birth Date

Month Day Year
Date

Address

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

Current Grade
Current School
Gender
Parent/Guardian Information

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

Area Code Phone Number
Relationship to student
Does the student live with you?
Emergency Contact OTHER THAN parent

First Name Last Name
Day Time Phone Number

Area Code Phone Number
Does your child have any of the following?

Activity restrictions Medical conditions Food Allergies Medication 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 no small electronic devices are allowed at Adventure Break Camp, including, but not limited to cell phones, tablets, video games, etc. Holy Trinity is not responsible for such items.

I understand that participation in this event is not without risk to me/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 youth.

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 center.
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:

Adventure Break Camp Registration

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