Summer Youth Camp - Family Registration
2022 Immaculate Heart of Mary's Camp starts July 11 with drop off between 8:45-9:00.  Please arrive at 11:55-12:00 for pick up each day.  Camp ends with Friday celebration starting at 11:45!
Meeting at Founders Hall entrance each day for drop off and pick up.
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Family Last Name *
Parents First and Last Name *
Parent Address *
Email address *
Phone Cell (Primary) *
Phone Cell (Secondary)
Phone home
(if different and not required)
Child #1 Name *
Child #1 Group
Camp Shirt Child #1
Child #2 Name
Child #2 Group
Camp Shirt Child #2
Child #3 Name
Child #3 Group
Camp Shirt Child #3
Child #4 Name
Child #4 Group
Camp Shirt Child #4
Families of 5+ registrants
Please complete an additional registration form online if you have more than four children to register for this camp. Once you submit, complete another form please. Thank you.
Can you volunteer during any of the following ways?
Select any and all that apply
Please verify that you are sending in payment BEFORE July 1st for Registration $20/ participant  ($20 late registration fee per family) *
Mail to : IHM - Summer Youth Camp, PO Box 100, New Melle, MO 63366, includes snacks and camp shirts
Please go online and LIKE our event and share it with friends please
Provide any questions you may have and the Camp Director will get back to you quickly.
If any child has any FOOD ALLERGIES?                      (list any foods to which your child is allergic. Please be very specific, also provide child's name)
Name one additional EMERGENCY CONTACT (not parent) that we would be abel to contact if the situation presents itself. Name and Phone number please *
Liability Release and Parental Consent Form

In consideration of the acceptance of my family regsitration for the Catholic Kids Camp 2016 program, I hereby
waive, release, and discharge any and all claims for damages for personal injury, property
damages or which may hereafter occur to me as a result of participation in said event.
This release is intended to discharge in advance Immaculate Heart of Mary,  its volunteers and staff, and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and
knowing those risks, I hereby assume those risks. It is further understood and agreed that
this waiver, release and assumption of risk is to be binding on my heirs and assignees.

I give consent for my child(ren) listed above to participate in the
above activities, and I execute the above liability release on their behalf.
Consent for Treatment
I hereby give my consent to have the above applicant treated by emergency medical
personnel, a physician, or surgeon, in case of sudden illness or injury while participating
in the above activity. It is understood that Immaculate Heart of Mary will provide no medial
insurance for such treatment, and that the cost thereof will be at my expense.
I have read and understood the foregoing registration liability release and parental
consent form, and agree to all of its terms and conditions. My digital signature below provides my consent.
Parental Consent (type name for digital signature) *
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