CAMP REDEEM REGISTRATION
See flyer below for details
Email address *
CAMP REDEEM Information
PARTICIPANT INFORMATION
Child's Name (First and Last) *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Age *
Your answer
Grade *
Your answer
Full Address *
Your answer
PARENT INFORMATION
Parent/Guardian Name (primary) *
Your answer
Parent/Guardian Phone Number (primary) *
Your answer
Parent/Guardian Address (primary) *
Your answer
Parent/Guardian Employer (primary) *
Your answer
Parent/Guardian Work# (primary) *
Your answer
Parent/Guardian Phone Name (Secondary) *
Your answer
Parent/Guardian Phone Number (Secondary) *
Your answer
Parent/Guardian Address (Secondary) *
Your answer
Parent/Guardian Employer (Secondary) *
Your answer
Parent/Guardian Work # (Secondary) *
Your answer
Permission to text Parent/Guardian *
Required
EMERGENCY CONTACT INFORMATION
Emergency Contact: If either Parent is unavailable who should we call? (List first and last name, phone number and relationship to child). *
Your answer
My child may be picked up by the following individuals (please list name and relationship to child): *
Your answer
MEDICAL INFORMATION
Please list Primary Care Physician, Location, and Phone Number *
Your answer
Does your child have any allergies? *
If yes, list all known allergies. *
Your answer
Does your child take any medication? Please be aware that our staff will not administer any medications. *
If yes, please list medications and their intended use.
Your answer
ADDITIONAL INFORMATION
Does your child have a library card?
What are your child's interests?
Your answer
Please list any additional information you feel like we should be aware of? *
Your answer
In order for your child to participate in CAMP REDEEM, please read and check off each consent listed.
Participation Consent - Safety and Behavior: I understand that my child's safety and the safety of those around him/her depends largely on my child's own behavior and actions. Any participants who does not comply with safety standards may be subject to dismissal. *
Required
Participation Consent - Safety and Behavior: I understand that the presence of program staff does not relieve my child of the responsibility of behaving appropriately, following instructions, dressing appropriately, and acting in a manner that does not put him/herself or others in danger. I further agree to encourage my child to follow Camp Redeem rules and guidelines including staff or supervisor instructions. *
Required
Participation Consent - Medical Care: I understand that every precaution is taken to secure the safety of each participant; however, in case of accident, I give permission for Camp Redeem and/or Redeeming Word Church staff to seek medical attention and understand I am responsible for the cost of care. *
Required
Participation Consent - Transportation: I give Camp Redeem staff permission to transport my child as needed to recreational activities. I understand that this transportation may be in a Redeeming Word Church vehicle or public transportation. *
Required
Participation Consent - Photo Permission: I give Camp Redeem staff permission to take and use photos of my child for the sole purpose of program marketing and publicity. *
Required
PAYMENT OPTIONS
Registration = $25 (one-time fee); Weekly Rate = $75 (one child); Each additional Child = $50. See image below for details.
How will you secure payment? *
Required
More Information...
A copy of your responses will be emailed to the address you provided.
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