2017 Beulah on the Road Registration Form
Trinity Evangelical UMC (Upper Sandusky, Ohio)
First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
City *
Your answer
State *
Zip Code *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
Age *
Your answer
Grade going into (by the end of June) *
Birthdate *
MM
/
DD
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YYYY
Gender (Female=1, Male=2) *
Required
Parent/Guardian(s) *
Your answer
Request to be in the same group as (optional):
Your answer
Allergies *
Required
Does your child have any life threatening allergies? If yes, please list. If no, simply write no. *
Your answer
Is your child bringing any medication with him/her, including an EpiPen or inhaler? If yes, please list. If no, simply write no. *
Your answer
Does your child have any physical, emotional, mental or behavioral concerns or limitation that our staff should be aware of? If yes, please describe. If no, simply write no. *
Your answer
In checking "yes" on this document, I hereby certify that I give permission to my son or daughter to participate in the camping program of Beulah Beach Camp & Retreat Center. I release my child’s info to be shared with both the host church and Beulah Beach. I give permission for my son or daughter to be transported in vehicles for camp approved transportation and activities. I also authorize Beulah Beach Camp & Retreat Center to use photographs, video, and/or audio clips of my child in camp publicity. In consideration of permission granted the herein named individuals to participate in camping activities, we hereby release and covenant with Beulah Beach Camp & Retreat Center that we will never, individually or as legal guardians of said individuals, institute any action at law or in equity for any personal injuries, or damages to property, real or personal, caused by, or arising out of camping and other related activities sponsored by Beulah Beach Camp& Retreat Center, its successors and legal representatives; we further agree to indemnify and hold Beulah Beach Camp & Retreat Center harmless against any and all costs, damages and expenses which may be incurred by them as a result of any lawsuit we might file against them. We understand and acknowledge that camp activities have inherent dangers that no amount of care, caution, instruction or expertise can eliminate and we and the participant expressly and voluntarily assume all risk of personal injury sustained while participating in aforementioned activities whether or not caused by the negligence of the released parties. *
Required
Authorized Adult(s) for Pick-up *
Your answer
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