Day Camp 2019 Sign Up Form
Please complete this form completely.
If you have any questions please contact:
First and Last
Participant's Phone Number
What Camp Are You Signing Up For?
Mini Camp (Ages 3-Completed K)
Day Camp (Camper Completed Grades 1-5)
What Are You Signing Up For?
Mini Camp Adult
Day Camp Adult
Mini Camp Junior Counselor (Completed 6th Grade)
Day Camp Junior Counselor (Completed 7-12 Grade)
**FOR MINI CAMPERS ONLY**-- Age as of September 1, 2018
This is the grade you completed in the 2018-2019 Academic School Year; If adult, please select "Adult" (Mini Campers do not need to complete this section)
**Adults please put down an emergency contact**
Parent/Guardian Best Phone Number
Parent/Guardian Email Address
Emergency Contact #2
Emergency Contact #2 Address
Emergency Contact #2 Best Phone Number
Please put Name of Insurer, Policy or Group Number.
Please list your primary care physician's name, number and address.
Any allergies/medical conditions/situations that the leaders need to be aware of? e.g.-- child not a swimmer (This will remain confidential)
Do you agree to the following statement?
In consideration for the allowing my child to participate in Day Camp and its activities, I/we do hereby agree to release and hold harmless the First Christian Church (DOC), Longview, TX, its employees, members and agents, from and against any and all demands, or causes of actions, that may arise from or be due in any way to such child's participation in Day Camp/Mini Camp and its related activities. Further, I release R. Byron Roach and wife, Anda Roach (ROACH hereafter) and Brack-Co, Inc. of all liabilities and claims which may otherwise accrue to me, including claims of negligence of the ROACH or by third parties that may be sustained by myself or my child while participating in or with respect to the Day Camp sponsored by First Christian Church (DOC), Longview, TX, including claims of personal injuries or death. I further agree to indemnify and hold harmless ROACH from any liability that they may incur to myself/my child howsoever arising and whether caused by the negligence of ROACH or third parties.
I have read and understand the foregoing relase and indemnity agreement.
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