Camp Fire Clubs Youth 2020-2021 Registration Form
To be filled out by parent/legal guardian
Email *
Youth Information
Youth's First Name, MI, Last Name *
0 points
Phone Number *
Secondary Phone Number
Address (Street, city, state, zip) *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Grade *
School *
Family Information
Father/Guardian's Name *
Address (if different)
Phone (if different)
Employer *
Work Phone *
Occupation
Hobbies/Interests/Other Organizations
Mother/Guardian's Name *
Address (if different)
Phone (if different)
Employer *
Work Phone *
Occupation
Hobbies/Interests/Other Organizations
Emergency Contact
Who should we contact if parents are unavailable?
Name *
Phone *
Secondary Phone
Address (Street, city, state, zip) *
Relationship *
The following individuals are allowed to pick up my child (list three) *
Club Information
We just need some basic info...
Club Name *
Leader Name *
Area *
Club Program Level *
Membership Status *
Membership Fee (membership year 9/1/19-8/31/20) *
Our Promise
Young People want to shape the world.

Camp Fire provides the opportunity to find their spark, lift their voice, and discover who they are.

At Camp Fire, it begins NOW.

Light the Fire Within
I accept the challenge of the promise and am adding $______ to my payment to give more youth the chance to benefit from the fun and friendship of Camp Fire Wilani.
This section is optional and will be used for statistical purposes only:
Ethnicity/Race
Clear selection
Disabilities (please specify)
Total # in Family
Clear selection
Household Income
Clear selection
Religious Preference
PARENT/LEGAL GUARDIAN PERMISSION
I give permission for my child (or ward) to become a member of Camp Fire Wilani. I will assist in observing the rules of the council and I waive any claims against Camp Fire Wilani and the council except for claims arising from gross negligence or willful acts of the council or its agents that may arise from participation in the activities of Camp Fire Wilani. I understand that reasonable measures will be taken to safeguard the health and safety of all participants and that I will be notified as soon as possible of any emergency affecting my child (or ward). In the event of an emergency and I cannot be reached, I hereby authorize the calling of a physician to provide whatever emergency medical or surgical treatment is necessary. I accept responsibility for the cost of medical treatments.

PHOTOGRAPHIC RELEASE: I consent to the taking and use of any slides, photographs, videotaping of my child during the program for advertising, promotion, publicity, or any other lawful purposes by Camp Fire Wilani now and in the future, whether that use is known to me or unknown. I agree and consent that Camp Fire Wilani may publish, broadcast, copyright for all purposes, the statements and/or pictures taken of my child and/or his/her property for advertising and public relations purposes. I waive the right to inspect or approve the photographs or electronic matter and waive the rights to royalties or other compensation arising from or related to the use of the photographs.

PRODUCT SALES: Each registered youth is required to participate in all product sales.
Electronic Signature
The parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purpose of validity, enforceability and admissibility.
Signature *
Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This form was created inside of Camp Fire WIlani. Report Abuse