Ebenezer Lutheran Church - Disciple Camp Registration 2017
Complete one for EACH camper!
Camp Dates: July 23-27, 2017
Day Campers: $170 ($200 after June 11)
Overnight Campers: $320 ($350 after June 11)
All registrations due by July 2
Camper's Grade In the Fall
rising 1st grade
rising 2nd grade
rising 3rd grade
rising 4th grade
rising 5th grade
rising 6th grade
rising 7th grade
rising 8th grade
rising 9th grade
rising 10th grade
List Any Health Conditions Staff Should Know About
Insurance Policy #
Insurance Company Name
Name and Phone # of Child's Physician
Does the camp director or other authorized person have permission to give your camper medical attention should it be needed?
List the name and phone number of the person we should contact should we need him/her during disciple camp (family and non-family contacts). List all phone number with clear descriptions (i.e., John's cell, Mary's work, grandmother landline, etc.)
Payment to be made (checks should be mailed to Ebenezer Lutheran Church, 1301 Richland Street, Columbia, SC 29201)
Day camper $170 ($200 after June 11)
Overnight Camper $320 ($350 after June 11)
Credit Card Information (name on card, card number, expiration date, security code on back, billing zip code)
Publication/Web Picture Permission - I grant permission for Ebenezer Lutheran Church to publish photos of my camper on the church's website or Facebook page. I give Ebenezer Lutheran Church the perpetual, royalty-free right to use my child's photo in any manner including in publications and websites. I understand that both the various publications and Websites have a large audience and my camper's photos will be available to the general public. I further understand that Ebenezer Lutheran Church assumes no liability or responsibility whatsoever concerning any consequences of such use. I further state that I have the right to give this permission as I am the camper's parent or legal guardian. I understand that if I give notice to any Ebenezer staff member or to the webmaster that I object to any particular picture on the website, it will be removed as soon as possible.
Yes, I grant permission for ELC to publish pictures of my camper
No, I refuse to grant permission for ELC to publish pictures of my camper.
If web photo permission is yes, include First Name on photos?
Yes, you may include my camper's first name with thier photos.
No, you may not include my camper's first name with their photos.
Signature of parent/guardian. By typing your FULL NAME you certify that this form is accurate to the best of your knowledge.
A copy of your responses will be emailed to the address you provided.
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