Valenteen 2019 Registration (February 16-18)
Thank you for your interest in Esperanza's Valenteen camp! This camp is for 12-19 year old teens and will cost $75 per person. This form does not guarantee you will get in, but it is a first come first serve so be sure to apply as soon as possible. This is to be filled out by parents or guardians of campers.
Email address *
Camper's name (First and Last)
Your answer
Camper's address
Your answer
Camper's gender *
Your answer
Any special requests (Like being in a cabin with someone specific, or not being in a cabin with someone specific, etc.)? No guarantees, but it doesn't hurt to ask.
Your answer
Camper's mailing address
Your answer
Where will you drop this camper off on Saturday the 16th at 10 am (If other, please explain)? *
Where will you pick this camper up on Monday at 2:30 pm (If other, please explain)?
Camper's birth date (month/day/year) *
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Medical number *
Your answer
Parent or guardian's name *
Your answer
Parent or guardian's phone number *
Your answer
Parent or guardian's email address *
Your answer
Emergency contact name *
Your answer
Emergency contact phone number *
Your answer
Emergency contact email address *
Your answer
Allergies and 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
Camp waiver *
I acknowledge that the activities associated with camp at a remote location include outdoor hikes, water sports, and ocean based transportation to and from the locations and that these involve both foreseeable and unforeseeable risks that could result in personal injury or death. I fully understand the risks and dangers involved in the activities and events associated with attending the summer camps put on by ESPERANZA MINISTRIES ASSOCIATION. I DECLARE that by allowing the below named person(s) to participate in the summer camps and the transportation provided by ESPERANZA MINISTRIES ASSOCIATION that I assume all risks and will hold the said association, its directors, members, employees, volunteers and agents harmless from any liability whatsoever which may arise out of such camp activities. I also agree to indemnify ESPERANZA MINISTRIES ASSOCIATION from any legal action brought upon them as a result of any injuries suffered by me or the below named person(s) in the summer camp and should ESPERANZA MINISTRIES ASSOCIATION be required to incur any legal costs, I agree to indemnify them for all such costs on a solicitor client basis. I realize that by signing this release I am prohibited from commencing a lawsuit against ESPERANZA MINISTRIES ASSOCIATION, its directors, members, employees, volunteers or agents, for any negligence on their part which gives ruse to injury to me or to the below named person(s).
Required
If the camper is under 19 years of age, please electronically sign the following statement. I am a parent or guardian of the above mentioned camper, who is 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. *
Signed (Parent or Guardian's name below):
Your answer
Do you understand that by signing typing your name above here that you are signing the waiver above it? *
Required
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, as the parent or guardian, as a signature.)
Your answer
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