CAMP CHALLENGE ON THE GO - 2020
Registration form for Summer 2020
Email address *
Parent/Guardian: *
Your answer
Address: *
Your answer
City, State, Zip: *
Your answer
Home Phone #
Your answer
Cell Phone #: *
Your answer
School District Residence *
Your answer
Number of Children to Attend the Program *
Your answer
Name of First Child *
Your answer
Date of Birth of First Child *
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Grade the Child will enter in the Fall 2020 *
Your answer
Name of Second Child to register
Your answer
Date of Birth of Second Child to register
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DD
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Grade the Second Child will enter in the fall of 2020
Your answer
Name of Third Child to register
Your answer
Date of Birth of Third Child to register
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DD
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Grade the Third Child will enter in the fall of 2020
Your answer
Does your child have access to the Internet *
LEMOYNE COMMUNITY CENTER ACTIVITIES – INDEMNIFICATION AND RELEASEI hereby represent that my child has no physical restrictions which would prohibit his participation in Camp Challenge On The Go activities. I, the undersigned parent/guardian, on behalf of myself, my heirs, legatees and assigns, agree to indemnify, save and hold harmless, the LeMoyne Community Center, Joyce D. Ellis, universities/colleges, program partners, and the LeMoyne Community Center staff or any of their agents, representatives, employees or assigns for my child’s health, safety, or any injury and/or disability arising out of or resulting from, the LeMoyne Center activities. By signing below, I acknowledge that I have read and understand this agreement, consent, and waiver and agree to abide by the information presented while my child is participating in the LeMoyne Center Camp Challenge On The Go Program.
PHOTOGRAPH/VIDEO RELEASE: The LeMoyne Community Center, its employees, agents, servants, and representatives may use the child’s name, photographic likeness whether alone or in a group, in any LeMoyne Community Center publication, document, television production, video, etc. In addition, the LeMoyne Center may release said name or likeness to any media outlets including but not limited to: newspapers, magazines, or television stations for publicity and/or recognition purposes. We will only use your child’s likeness in an effort to enhance the LeMoyne Community Center and the community itself. Additionally, by signing below, I extend permission to use the child’s name and/or photographic likeness, alone or in a group, on the official website, not excluding the LeMoyne Community Center’s official Facebook page. The official website is owned and maintained by the LeMoyne Community Center as a service to parents, children, and the community.
Photograph/video release *
By typing my name below I acknowledge that I have read, understand and agree to abide by the sections above, specifically Indemnification and Release and Photograph/Video Release. *
Your answer
Date of application *
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