Registration 
  • Adventure day trips each day!!!  
  • $575 per child per week.  
  • $75 off each additional child.
  • 40% non refundable deposit required per camp week ($230).  
  • Payment plans will be accepted(contact us to inquire about this option).  
  • Final payment due June 1, 2024.
  • The first 40 campers registered will automatically be granted entrance to our camp. Any registrants over 40, will go on the waitlist until we have enough staff and campers for a second bus. If we can’t fulfill that, your money will be refunded.
  • Accepted methods of payment will be:
  1. Zelle - rockadventurecompany@gmail.com
  2. Check made out to ROCK Adventure Company -  Mail to:                                                                                           ROCK Adventure Company, 8 Kent Place, Pompton Plains, NJ 07444
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Email *
GET READY TO R.O.C.K.
Participant's Name *
Sex  *
Address *
Participant's Birth Date  *
MM
/
DD
/
YYYY
Please list the participant's Health Insurance Company 
(Optional)
Please list the Health Insurance Company Policy and Group Number
(Optional)
Primary Physician (Optional)
1. Name and Phone Number 
Medications Presently Taken 
If NO medications are necessary please type N/A
 *
Past Illness or other information that would be useful in the event that treatment is necessary:

If there are none please type N/A
 *
Allergies 
Please list any allergies
If there are No allergies please list N/A
 *
I hereby give R.O.C.K. Adventure Company Staff permission to administer an Epipen to my child.  Sign name below along with instructions.
Participant's Grade for the 2024-2025 School Year  *
What is the participant's favorite song? *
Do you have any special instructions you would like to share with us about your child? *
Please tell us about your child's likes/dislikes?
What are they good at?  What do they want to work on?
Really anything you want us to know about your AWESOME child so we can get to know them better before camp. 
 *
Participant's T-Shirt Size  *
Date Choice of Camp *
Parent/Guardian- 1
Name
 *
Parent/Guardian- 1
Address (if different than participant)
Parent/Guardian- 1
Phone Number 
 *
Parent/Guardian- 1
Email 
 *
Parent/Guardian- 2
Name 
 *
Parent/Guardian- 2
Address (if different than participant)
Parent/Guardian- 2
Phone Number 
 *
Parent/Guardian- 2
Email 
 *
Emergency Contact Name: 

 *
Emergency contact address: *
Emergency Contact Phone Number: *
Emergency Contact Email *
Emergency Contact Relationship to Participant: *
Please list 3 people that are authorized to pick up your child from camp. 
1. Name- relationship to participant 
2. Name- relationship to participant
3. Name-relationship to participant 
 *
Payment Information 
$575 per child per week.  
$75 off each additional child.
40% non refundable deposit required per camp week ($230).  
Payment plans will be accepted(contact us to inquire about this option).  
Final payment due June 1, 2024.
 *
R.O.C.K Adventure Company
Waiver of Liability

1. The undersigned parent or legal guardian and participant hereby acknowledges that participating in the
above R.O.C.K Adventure Company events and activities carries with it the potential risk to injury, and as
such the undersigned hereby assumes the risk of such possible injury. I do understand that there is a small
risk of potential catastrophic injury by participating.  I assume financial and legal responsibility for any
injury or injuries suffered during participation in any of the events or activities. I am aware of the risks and
assume responsibilities associated with participation in the events or activities.

2. Recognizing the possibility of physical injury associated and in consideration for R.O.C.K Adventure
Company accepting the registrant for its programs and activities (“the programs”), I hereby release,
discharge and/or indemnify R.O.C.K. Adventure Company, its directors, coaches, sponsors, employees and associated personnel, including the facilities utilized for the Programs, against any claim, loss, damage or
other disability.  

3. R.O.C.K. Adventure Company, its employees or agents are not responsible for accidents and medical and
dental expenses incurred as a result of participation in this program.  

4. My child is covered by family/personal insurance and is in good health and able to participate in the
physical activity of a rigorous program.  

5. For myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and
next to kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above releases from any and all liabilities
incident to my involvement or participation in these programs, EVEN IF ARISING FROM THEIR
NEGLIGENCE, to the fullest extent permitted by law.

6.  I give permission for my child to be photographed and pictures to be used for branding, social media publications, etc. 

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS
TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND
VOLUNTARILY WITHOUT ANY INDUCEMENT.


In consideration of my child listed above, being allowed to participate in any way in any
of the R.O.C.K Adventure Company’s related events and activities the undersigned acknowledges and agrees. 

I declare that I am the Father/Mother/Guardian of the above named minor. 
By typing your name below you are accepting this as your digital signature.
 *
A copy of your responses will be emailed to the address you provided.
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