R.E.R.M. Youth Summer Excursion 2019
1. Please fill out and complete.
2. If child has ever attended a Duval County Public School, you must provide student ID.
3. Please attach necessary documentation. Any one of the below mentioned documents:
a. Report card from a public school that receives 100% Free and Reduced Lunch. (Title 1 School)
b. Copy of Florida Tax Credit Scholarship (i.e. Hero scholarship, Step up, etc..)
Email address *
Parent or Guardian Name *
First and last name
Your answer
Email *
Your answer
Phone number *
Your answer
Student First Name *
Your answer
Student Last Name *
Your answer
Date of Birth *
Your answer
Age *
Your answer
School *
Your answer
Student ID *
Your answer
Grade Level *
Your answer
Ethnicity
Address *
Your answer
City *
Your answer
Zipcode *
Your answer
Emergency Contact: Person to be contacted in case of illness, accident, emergency and authorized to remove the child from the facility in theabsence of a parent/guardian. If none, please indicate none. *
Your answer
Emergency Contact: Address *
Your answer
Emergency Contact: Phone Number *
Your answer
Emergency Contact: Relationship to child *
Your answer
Please list all individuals who can safely remove the child. Name, Address, and Phone Number *
Your answer
General Release of Liability: In consideration of being allowed to participate in any way in RERM Youth Summer Excursion and related events and activities the undersigned agrees to the following: I acknowledge and fully understand that each participant may be engaging in activities that involve risk or serious injury; including permanent disability and severe social and economic losses, which might result from their actions, inactions or negligence, but the actions, inactions or negligence of others, the rules of play or the condition of the premises of any equipment used. Further, that there may be risks not known to us or not reasonably foreseeable at this time. To the best of my knowledge, my son/daughter is physically fit to engage in the activity in question. I understand that the Kings Road Church of Christ, the Kids Hope Alliance, Abundant Life Ministry and GEERS and their employees and agents will exercise reasonable care while my son/daughter is in their custody and care engaging in activities through the RERM Youth Summer Excursion 2019. I agree to hold the Kids Hope Alliance, Kings Road Church of Christ, Abundant Life Ministry, Men of Loyalty, and GEERS and its employees and agents harmless from any and all liability, which may arise while exercising their duty or care, relating to my son/daughter for personal injury or illness that may be suffered or loss of property that may occur to my son/daughter while participating in RERM Youth Summer Excursion 2019. Typing your name on the line will be your signature agreeing to the General Release of Liability. *
Your answer
Photo/Media Release: I acknowledge and understand publicity activities such as interviews, photos, and videotaping may occur. I consent and permit my child as a participant in RERM Youth Summer Excursion 2019, to be photographed, videotaped, and/or interviewed for publicity activities. *
Photo/Media Release: Typing your name on the line below is your consent and agreement to the above Photo/Media Release statement. *
Your answer
Parent/Guardian is responsible for transportation of youth to camp. Elementary age participants must be picked up by an authorized person 18+ and must be able to show identification. Students must be picked up at the designated camp end time. Failure to comply may result in camper being removed from the camp. Typing your name on the line below is your consent and agreement with this statement. *
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