Signature Event Waiver Form
For all guests attending a Signature Event.
Contact Information
Camper/Guest Name
*
First Name
Last Name
Camper/Guest Email
*
example@example.com
Camper/Guest Phone
*
Please enter a valid phone number.
Camper/Guest Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Visit Information
Group Name
*
Please Select
Beech Park
Bible BC KY
Bible BC VA
Central
Day Camp
Edgemont Junior
Enon
Ewtonville
Fairview CHURCH TEEN
Fairview TABERNACLE JR
FBC Barberville
FBC Hazel Park
FBC Pikeville Jr
FBC Pikeville Man Camp
FBC Pikeville Teen
Floyd Road BC JR
Floyd Road BC Teen
Friends
Friends BC
Friendship Teen 1
Friendship Teen 2
Gardendale Baptist Tabernacle
Grace Baptist Temple
New Home Teen 2
New Home Junior
Oaklawn Teen Camp
Oaklawn Man Camp
Walter
West Huntsville BC
Name of your church or school
Event Name
*
Please Select
Breakaway
Man Camp
Junior Camp
Day Camp
Teen Camp 1
Teen Camp 2
Seasons
Arrival Date
*
-
Month
-
Day
Year
Date
Departure Date
*
-
Month
-
Day
Year
Date
T-Shirt Size
*
Please Select
Child Small
Child Medium
Child Large
Adult Small
Adult Medium
Adult Large
Adult X Large
Adult XX Large
Adult XXX Large
Gender
*
Male
Female
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Any Food Allergies?
*
Yes
No
List Food Allergies
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Emergency Contact
EC Name
*
First Name
Last Name
EC Phone
*
Please enter a valid phone number.
Is Guest aged 17 or younger
*
Please Select
Yes
No
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Minor Information
Please complete in full and to the best of your knowledge
Camper Birthdate
*
-
Month
-
Day
Year
Date
Camper Age
*
Please Select
17
16
15
14
13
12
11
10
9
8
7
6
5
Parent/Guardian Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone
*
Please enter a valid phone number.
Parent/Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Insurance Information
Type of Insurance
*
Please Select
Family Health
Medical Insurance
Self Pay
Insurance Carrier/Family Medical Name
*
Name of Insured
*
First Name
Last Name
Relationship to Camper
*
Insurance/Group Number
*
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Medical Information
Immunizations Up to Date
*
Yes
No
Currently Taking Medication
*
Yes
No
Medications
Dosage
Chronic or Recurring Illness or Medical Condition
*
If none, type "None"
Any Activitiy Restrictions?
*
Please Select
Yes
No
Health or Medical Concerns
*
Insurance Card
Browse Files
Drag and drop files here
Choose a file
Upload both sides of Insurance Card
Cancel
of
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Guest Signature
*
Legal Name
*
First Name
Last Name
Parent/Guardian Signature 1
*
Parent/Guardian Name 1
*
First Name
Last Name
Parent/Guardian Signature 2
*
Parent/Guardian Signature 2
*
First Name
Last Name
Submit
Should be Empty: