Day Camp 2019 Sign Up Form
Please complete this form completely.

If you have any questions please contact:

Lyn Blount

Participant's Name *
First and Last
Your answer
Participant's Address *
Your answer
Participant's Phone Number *
Your answer
Gender *
What Camp Are You Signing Up For? *
What Are You Signing Up For?
**FOR MINI CAMPERS ONLY**-- Age as of September 1, 2018
Your answer
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)
Birthday *
Your answer
T-Shirt Size *
Parent/Guardian's Name *
**Adults please put down an emergency contact**
Your answer
Parent/Guardian Address *
Your answer
Parent/Guardian Best Phone Number *
Your answer
Parent/Guardian Email Address *
Your answer
Emergency Contact #2 *
Your answer
Emergency Contact #2 Address *
Your answer
Emergency Contact #2 Best Phone Number *
Your answer
Insurance Information *
Please put Name of Insurer, Policy or Group Number.
Your answer
Physician Information *
Please list your primary care physician's name, number and address.
Your answer
Dietary Restrictions? *
Food Allergies? *
Any allergies/medical conditions/situations that the leaders need to be aware of? e.g.-- child not a swimmer (This will remain confidential) *
Your answer
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.
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