Fernwood Detailed Registration Form

REGISTRATION FORM

Participants Name*

First NameLast Name

Birth Date*

MonthDayYear

Grade entering*

Address

Street Address

CityState / Province

Postal / Zip CodeCountry

Email

example@example.com

Home Church

Church NamePastors name

I would like to purchase a t-shirt for the selected program

YESNO

Shirt Size

Program Attending*

Name*

First NameLast Name

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

E-mail

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Do/does you/your child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Are you/is your child prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Fernwood Christian Camp during the selected camp. In exchange for the acceptance of said child’s candidacy by Fernwood Christian Camp, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Fernwood Christian Camp and the sponsoring/host church and all its respective staff members, pastors, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Fernwood Christian Camp; including all staff members and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Medical Release and Authorization

As Parent and/or Guardian of the named child, I hereby consent in the activities provided by Fernwood Christian Camp along with any other sponsoring church. If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them in the areas provided above. In the event that an emergency occurs, I hereby authorize an adult in charge of said group to make emergency medical decisions for my child, including consent of surgery, injection, anesthesia, or dentistry if required. If there are any activities I do not want my child involved in, I have listed them in the areas provided above. My insurance shall be primary and the insurance of the sponsoring church will be secondary.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Signature*

My Products

2nd-6th Grade Day Camp Registration$30.00

Teen Camp $155.00

7th-12th Grade

Servants Week Registration$110.00

8th-12th Grade

Jr. Camp Week 1$145.00

3rd-6th Grade

Leadership Camp$145.00

8th-12th Grade

3 Week Teen Program$325.00

All Three Teen Weeks packaged

Teen Adventure$165.00

7th-12th Grade

Start Now Rally$ Free

6th-12th grade

Winter Conference $15.00

6th grade- 12th grade

Total $0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Select week(s) attending

Parent/Guardian Information