Middle School Camp Registration

Participant Information

Participant's Name

Participant's Birthdate

Participant's Age as of June 22, 2021

Participant's Grade as of Fall, 2020

Participant's Gender

Father/Male Guardian Information

Father/Male Guardian

Father/Male Guardian Address

Father/Male Guardian Phone

Father/Male Guardian Email

This address will receive a confirmation email

Mother/Female Guardian Information

Mother/Female Guardian Name

Mother/Female Guardian Address

Mother/Female Guardian Phone

Mother/Female Guardian Email

This address will receive a confirmation email

Transportation Assistance

Are you (the parent) able to help in transportation either to or from camp?

Yes No

If you are available, please provide some additional information about your availability (Are you available on June 23, 26, or both? How many kids could your transport?).

Medical History

NOTE: Neither Clifton Baptist Church nor its caregivers will administer prescription or over-the-counter medications of any kind, in any circumstances, with the exception of epinephrine injectors. If an epinephrine injector is necessary for your child, please contact the Nursery Coordinator, Children’s Ministry Director, and/or Youth Minister. It will be the parents’ responsibility to properly train the caregivers in the proper administration of an epinephrine injector.

Please provide any significant medical history, psychological history, or other pertinent information that will be useful or necessary in caring for your child or in an emergency. Please be as complete as possible.

Please list any known allergies, including allergies to medication and food:

Dietary restrictions. Please state whether for medical or other reasons:

Please list any current medications your child is taking:

Is your child up-to-date on their Tetanus booster?

Yes No I don't know

Date of last Tetanus booster (if applicable)

Physician's Name

Physician's Phone

Emergency Notification

If I am unavailable in the case of emergency please notify:

Emergency Contact's Name

Emergency Contact's Phone

Emergency Contact's Alternate Phone

Permission

I do hereby give permission for my above-named child to participate in ALL programs and events sponsored by Clifton Baptist Church, of Louisville, Kentucky, whether at church or off-site and transportation to and from any programs and events.

I understand that, in the case of an emergency Clifton Baptist Church, employees, agents, members and/or sponsors will make every effort to contact me and/or the contact person named on the reverse side; however,

Should the named contact person, or myself, be unavailable to make decisions regarding my child’s care, I do hereby grant permission for Clifton Baptist Church employees, agents, members, and/or sponsors to obtain emergency medical attention in case of sickness or injury, to my child, up to and including hospitalization and I understand that I am responsible for any expenses incurred.

Should the named person or myself be unavailable to make decisions regarding my child’s care, I do hereby grant permission for an attending physician or hospital to perform whatever care is deemed necessary for the welfare of my child.

***If you choose to later revoke this permission/release it must be done in writing. ***

Hold Harmless

I hereby release, absolve, indemnify, hold harmless, and forever discharge Clifton Baptist Church, its employees, agents, organizers, sponsors, members, or any supervisors appointed by them from any and all claims, demands, actions or cause of actions, past, present, or future arising out of injury or damage to my child while participating in any program or event, or from any check-in/check-out policy.

I assume all risks and hazards incidental to the conduct of the programs or events and check-in/check-out policy. In case of injury to my child, I hereby waive all claims against Clifton Baptist Church, its employees, agents, organizers, sponsors, members, or any supervisors appointed by them.

***If you choose to later revoke this permission/release it must be done in writing. ***

Father/Male Guardian Electronic Signature

By entering your full name in this field you agree to the above terms. You are also agreeing that this electronic signature is the same as a handwritten signature for the purposes of validity, enforceability and admissibility.

You may opt out of an electronic signature by requesting a paper copy of this document from the sending party, which you can then sign and return in person.

Father/Male Guardian Electronic Signature

Date of Signature

Mother/Female Guardian Electronic Signature

You may opt out of an electronic signature by requesting a paper copy of this document from the sending party, which you can then sign and return in person.

Mother/Female Guardian Electronic Signature

Date of Signature

Country Lake Christian Retreat Participation Agreement

Country Lake Christian Retreat requires that every participant complete the following form: https://form.jotform.com/CountryLake/clcr-adventure-zone-waiver

Check this box once you have completed the Country Lake Christian Retreat Participation Agreement for this participant.

Completed

Payment

The cost for each participant in the middle school camp is $222.

Payment

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Middle School Camp Registration

Description

Please Fix the Following