CHAMPS CAMP CAMPER REGISTRATION

Parent/Guardian Name *

First Name

Last Name

Cell Phone *

(###)

###

####

Alternate Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you currently have a church home?

Yes

No

Emergency Contact One *

First Name

Last Name

Phone Number *

(###)

###

####

Emergency Contact Two *

First Name

Last Name

Phone Number *

(###)

###

####

Does your child have any health concerns or allergies we should be aware of? *

Yes

No

Is your child on any medication that needs to be given during camp? *

Yes

No

LIABILITY RELEASE *

I hereby give my consent for the child listed above to participate in Champs Camp. I agree to hold harmless the Round Rock Church of Christ, its employees, and the Champs Camp staff from any and all liability from injury, claims, costs or loss of service which might be incurred by participation in said programs, activities, or events. I, the undersigned parent or guardian authorize the camp director or assistant camp director to secure any and all necessary treatment for the named camper in the case of any emergency, illness or accident. I, the undersigned, specifically release Round Rock Church of Christ and any parent or camp staff from responsibility for any accident or illness that may occur during the week of camp. I have read the above statements carefully and sign it voluntarily with full knowledge of its significance.

I agree to the above terms.

PHOTO RELEASE *

Throughout Champs Camp images will be captured on photo or video and posted on the church website (www.rrcoc.org) and/or Facebook account for families to view later. (Names and personal information will not be disclosed.) Please indicate consent or denial below.

I give my consent to photograph/video my child.

Please do NOT photograph/video my child.