Camp Overflow 2019

Youth's Name:

Youth Cell Phone:

Youth Email:

Gender:

Shirt Size (Adult Sizes)

Have you been a leader at Camp Overflow before?

If you were invited by a friend, who invited you?

Household Address:

Household Phone:

Household Email:

This address will receive a confirmation email

School:

Grade Level for 2019-2020:

Participant Date of Birth:

First Emergency Contact Name and Phone Number:

Second Emergency Contact Name and Phone Number:

Medical Insurance and Policy Number:

Physician and Phone Number:

Please list any illnesses or allergies, disabilities or special needs, and ALL prescription medications:

Any other information that event leaders need to know:

Is there anyone that should not be allowed to pick up your child?

I understand it is my responsibility for transportation of my child should an illness or accident occur. In the event that my child becomes severely ill or injured, the LCC personnel / adult leader has my permission to proceed with proper first aid and emergency medical care for my child, including ambulance services to the nearest medical facility.

YES

I also declare my allowance for me/my child(ren) to participate and recognize that participation in these activities may result in unintentional physical or emotional injury. In consideration of the privilege to participate extended to my child by Lapeer Community Church, I hereby, for myself and my child, my heirs, executor, and/or administrator, forever release and discharge Lapeer Community Church and its staff and volunteers from any liability while participating individually or with others in said events. I have endeavored to become fully aware of the nature of the events in all aspects. I entrust myself/my child(ren) to the leaders of the trip, agree to their method and means of transportation and support all their trip decisions accordingly.

YES

I agree that any photographs or video of me or my child(ren) may be used by other participants and the church to promote youth activities and any other publicity for ministry purposes.

YES NO

Parent or Guardian's Consent (Please type full name):

Date of Signature:

Payment (Select Option)

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Camp Overflow 2019

Description

Please Fix the Following