Youth Camp Student Registration

Your Information

Your Name (Parent or Guardian)(Required)
First Last

Your Email(Required)
Enter Email Confirm Email

Family Address(Required)
Street Address Address Line 2 City State ZIP Code

Your Cell Phone(Required)

Church city/name:(Required)

Family Insurance Information

Insurance Company

Group #

Policy Number

Other insurance information or indication of no insurance.

Permission and Release

PERMISSION TO PARTICIPATE: We (I) the parent(s) or legal guardian(s) of the student named on this form hereby grant our (my) permission for the student to participate fully in camp activities July 26-30, 2021.

MEDICAL TREATMENT PERMISSION: We (I) authorize an adult camp staff member, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned student pursuant to this authorization.

PHOTO & VIDEO RELEASE: I understand and grant permission for the student's image and voice to be captured in photography, video or audio during camp, and that image shall be the property of Open Bible Central Region for promotional use.

Electronic Signature (parent / guardian typed name)(Required)

Signature Authorization(Required)
I understand that checking this box constitutes a legal signature confirming that, to the best of my knowledge, the above information is complete and correct, that I am legally authorized to register the student(s) submitted with this form, and acknowledge and agree to the above Permission and Release.

Final Cost

This is for informational purposes only. Please turn in finances to your youth director. Price may increase or decrease based off of local church decisions for transportation as well as fundraising.

Total

2022 Youth Camp Registration

Student 2

Student 3

Student 4

Student 5

Your Information

Family Insurance Information

Permission and Release

Final Cost

Title

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