Kilombo : M.A.D Summer Camp Registration
Email address *
Child Name *
Child Name (2)
Child Name (3)
Birth Date *
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Birth Date (Child 2)
MM
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DD
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YYYY
Birth Date (Child 3)
MM
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DD
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Age (at start of camp) *
Age (child 2)
Age (child 3
Gender *
Gender (child 2)
Gender (child 3)
How did you hear about us? *
Address *
Parent/Guardian Information *
Name, Home/Cell Number, Email
Emergency Contact *
Contact's Name, Relationship, Phone Number, Atl. Phone Number
Does the camper have any allergies, chronic illness, or medical conditions? If yes, please describe. *
Is the camper prescribed an inhaler or any medications? If yes, please explain any instructions. *
Informed Consent and Acknowledgement *
I hereby give my approval for my child’s participation in any and all activities prepared by during the selected camp. In exchange for the acceptance of said child’s candidacy by ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions. In case of injury to said child, I hereby waive all claims against including all staff and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured in some activities.
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