2017 On-Line Summer Stomp Camp Registration Form
2017 On-Line Summer Stomp Camp Registration Form
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2017 On-Line Summer Stomp Camp Registration Form
Name of Child
Your answer
Complete Address
Your answer
Best Phone Contact Number
Your answer
Age of Child (Must Be At Least 6 Years of Age)
Your answer
Male or Female
What School Grade Level will this child enter in September?
What is the name of the Church this Child attends?
Your answer
Do you have a choice for one Roommate? If "YES", please type their FULL NAME in the space below. (*NOTE: Your Choice MUST be in your Cabin Division - either 2nd-3rd grade or 4th-6th grade)
Your answer
Transportation: How will this child be coming to Camp?
What is this child's T-Shirt Size?
PARENT/GUARDIAN AUTHORIZATION INFO
In Case of an Emergency Please Contact:
Name:
Your answer
Home Telephone Number:
Your answer
Work Telephone Number (and Extension if applicable)
Your answer
Cell Phone Number:
Your answer
REGISTRATION FOR CAMP:
Early Registration is Sunday, June 11 and June 18, following the 10:45am service and before the evening services at Church of the Open Door, Room 417.
Day of Camp Registration is Monday, June 19, 8:00am - 10:00am, at Church of the Open Door, Room 417
MEDICAL AUTHORIZATION/RELEASE OF LIABILITY:
In case of Medical Emergency, I hereby give my permission to the Staff Member in charge to: Hospitalize and/or secure the services of a licensed physician in providing necessary care for my child as named on this Registration Form. I certify that my child is in good physical condition and is able to participate in the entire Camping Program except for activities listed as "Restricted". Please indicate Activity Restrictions beside Signature/Name of Parent/Guardian below:
Signature/Name of Parent/Guardian and any Activity Restrictions
Your answer
CAMPER AGREEMENT:
I have carefully read the General Information and I agree to cooperate and comply in all these areas. I understand that violation of these areas may result in my dismissal from Camp.
Signature/Name of Camper and Date Signed
Your answer
PUBLICITY RELEASE AUTHORIZATION:
I grant Church of the Open Door, Pastor Atkinson and staff the right to take photographs of my child while at Summer Stomp Jr. Camp. I authorize Church of the Open Door, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Church of the Open Door may use such photographs of my child with or without his/her name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, and Web content. I have read and understand the above:
Signature/Name of Parent/Guardian and Date Signed
Your answer
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