Elevate Junior High Camp Student Registration Form
June 3-7, 2019 @ Trinity Pines
Registration Opens: February 1, 2019
Registration Payment Dates:
EARLY BIRD REGISTRATION: $335** (February 1- March 3, 2019)

REGULAR REGISTRATION: $350** (March 4th - May 19 or when spots are filled)

**Deposit of $100 due at Registration in order to reserve spot and get registration prices!

PAY ONLINE AT https://goo.gl/pp11dL
Payment (cash or check) also accepted on Sunday mornings at the Next Gen Center in the Foyer

All deposits are non-refundable.

Student's Information
First Name *
Your answer
Last Name *
Your answer
Current Grade (2018-19 School year) *
What school do you attend? *
Your answer
Gender *
T-shirt Size *
Age *
Your answer
Birthday *
MM
/
DD
/
YYYY
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Name TWO friends your student would like to room with during retreat *
Your answer
Small Group Leader's Name (if in one)
Your answer
What BPF campus does your student attend? *
Parent/Guardian Name(s) *
Your answer
Address *
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Parent's Current Email (important camp information will be sent to this email) *
Your answer
Parent's Email #2
Your answer
Parent's Cell Phone Number *
Your answer
Parent's Cell Phone Number #2
Your answer
Emergency Contact's Name *
Your answer
Relationship to Student *
Your answer
Cell Phone Number *
Your answer
Alternate Emergency Contact's Name
Your answer
Relationship to Student
Your answer
Cell Phone Number
Your answer
Family Physician's Name *
Your answer
Family Physician's Number *
Your answer
Does your student have Health Insurance? *
Name of Insurance Policy
Your answer
Insured Name
Your answer
Policy Number
Your answer
ID Number
Your answer
Insurance Phone Number
Your answer
Place of Employment
Your answer
Generally, my child's health is: *
If fair or poor, please explain your student's condition:
Your answer
Does your student plan to bring any medications to camp with them? *
If yes, please list medications:
Your answer
May your student have the following at medicine: (please check the ones that are approved) *
Required
Previous/Recent Serious Injury or Surgery? *
Chronic Medical Condition? *
If YES to any of the above, please describe:
Your answer
Date of Last Tetanus Shot *
Your answer
Allergies? (Food, Drugs, Insect Stings/Bites, etc) *
Your answer
I,_______________, Parent or legal guardian of_________________, a minor, hereby acknowledge that said minor is presently under my care, custody and control. I hereby give this minor my permission to go to Elevate Junior High Camp on June 3-7, 2019. I further grant my permission for this child to participate in all activities of said camp. I have listed any physical limitations or medical problems that may need attention. In the event there arises an emergency, necessitating medical attention, I hereby consent and give my permission to Brazos Pointe Fellowship representatives, camp sponsors, or any attending physician to make such decisions and to perform such medical treatment and/or surgery upon said minor, which may in their sole discretion be necessary and proper under the circumstances. I understand that every effort will be made to contact me in the event of such an emergency. I do release, acquit, discharge and covenant to hold harmless the encampment, and its personnel, all representatives of Brazos Pointe Fellowship, Lake Jackson, TX , from any and all actions, damages, liabilities arising out of the treatment of any sickness or accident incurred by said child during the camp dates. I also give authority and permission to camp sponsors to inspect my student’s room and belongings while on camp grounds for the safety and protection of all participants if circumstances make it necessary. I understand that my child/student will be dismissed from camp and sent home at my expense if he or she does not adhere to camp rules.Parent and/or Guardian (or student 18 years of age or over in agreement with above waiver). *
Your answer
Photo/Video/Movie Release
NOTE: To be completed by parents or legal guardian of participants under 18 years of age.
I, ________________, parent of _______________, a minor, hereby give permission to Brazos Pointe Fellowship to photograph my child and use such photographs in all forms of BPF media, for any and all promotional purposes including publicity, display and audiovisual use.I understand that the term “photograph” as used herein encompasses both still photographs and audio and video recording footage. *
Your answer
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