Esperanza Summer Camp Registration 2017
To be filled out by parents or guardians of campers.
Email address
I AM REGISTERING FOR:
CAMPER'S FIRST AND LAST NAME
Your answer
CAMPER'S MAILING ADDRESS
Your answer
CAMPER'S BIRTHDATE (month/day/year)
MM
/
DD
/
YYYY
Where will you drop your kids off?
MEDICAL NUMBER
Your answer
PARENT OR GUARDIAN'S NAME
Your answer
PARENT OR GUARDIAN'S PHONE NUMBER
Your answer
PARENT OR GUARDIAN'S E-MAIL ADDRESS
Your answer
EMERGENCY CONTACT NAME AND NUMBER
Your answer
ALLERGIES/MEDICAL CONDITIONS
Please list allergies, medical concerns, present prescriptions, problems with bedwetting, or any other information that would be beneficial for us to know about your child.
Your answer
PICTURES
Check the box that applies to you:
Required
Payment
NOTE: You will receive a payment request form 2 weeks prior to camp. Please DON'T transfer a payment before then. Please indicate how you are planning to pay for camp so that we can send you the necessary instructions? If a Band is sponsoring your camper, please add the name of the Band in the "OTHER" box.
Required
CAMP WAIVER
Type your name as an agreement.I, ______________________________________, am/are the parent(s) or guardian(s)
Your answer
CAMP WAIVER
(Please check all the boxes)
Required
I am/are the parent(s) or guardian(s)
(Your name below.)
Your answer
of ___________________________________________________, who is/are under the age of 19. I fully understand the risks and dangers involved in the programs and experiences offered at the facilities run by ESPERANZA MINISTRIES ASSOCIATION. In consideration of ESPERANZA MINISTRIES ASSOCIATION offering the programs and opportunities to the above named person(s), I agree to assume all risks involved. This release and assumption of risk is binding upon me, my heirs, executors, administrators and successors.
(Camper's name below.)
Your answer
I have read and clearly understand this liability release. I am at least 19 years old. Participant/Parent/Guardian’s Name
(Please enter your name, the parent or guardian, as a signature.)
Your answer
Please complete the captcha before submitting the form.
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