Camp Fearless 2024 - Student Registration

Please register each student seperately

Student Name

Student Birthdate

Student Gender

Male Female

Address

T-Shirt Size

Sm M L XL 2XL 3XL

Student Photo for ID

Upload (8MB)

Church Information

Church Name

The cost of camp will be paid through your church, however, if you would like to participat in one of our "add-on" activities you must pay through this form.

1) Horseback riding - $36.25
2) Tower of Faith (2 climbing walls with 4 skill levels, zipline, & leap of faith minumum 65 pounds - max 250 pounds) - $27

Add on activity (optional)

Parent/Guardian Information

Parent/Guardian Name

Relationship to Student

Parent/Guardian Email

This address will receive a confirmation email

Parent/Guardian Address

Parent/Guardian Phone (Emergency Contact)

Alternate Emergency Contact Name

Alternate Emergency Contact Phone Number

Alternate Emergency Contact Relationship to Student

Medical

If your child has any pre-existing or present medical conditions please explain

If your child has any activity limitations please explain

Please list any serious allergies

Insurance Provider

Insurance ID Number

Medical Release of Liability

In case of a minor injury or illness, please list any over-the-counter medicine you DO NOT want your child to take (tylenol, benadryl, calamine lotion, dramamine, hydrocortisone cream, ibuprofen, insect repellent, midol, milk of magnesia, pepto-bismol, sunscreen, triple antibiotic ointment, tums, etc)

If your child takes medicine on a daily basis it is the parent/guardian responsiblity to provide up-to-date and accurate medical dosage information. Registered nurses will be storing and administering all medication. It is the student's responsiblity to visit the nurses clinic at the appropriate dosage time.

Does your student have medicine that must be taken on a daily basis while he/she is at camp?

yes no

If so, please list Medicine(s) name, strength, frequency, dosage, times, & how to administer

I understand that all medicines must be in the original container and properly labled including the prescribing physicians name and contact information

I realize the importance of administering medication to my child in a timely manner, and do hereby agree to release Camp Fearless, The Seed Church and affiliates of any liability from any injury or death as a result of their administration of medicines to my child as prescribed above or on over the counter medication list. I have had the opportunity to discuss this with my physician and/or legal counsel and realize its ramifications and thoroughly understand the meanings of these statements. By typing my name I am signing in agreement.

Consent & Release Signature

I release the staff of Camp Fearless, The Seed Church and affiliates from any liabilities, claims and demands arising out of injury or accident incurred by my child while they are participating in any event while at Camp Fearless and or on the grounds of Camp Kulaqua. In the event of an accident or injury and I cannot be reached, I further authorize the executive staff of Camp Fearless to administer any medical treatment they may deem necessary for my child's well being.

I understand that The Seed Church and its affilitates photograph and digitally record participants while at events including Camp Fearless. By typing my name I am giving my signature and am giving permision to use any photos or videos taken of my child while at camp to be published by Camp Fearless and The Seed Church. I waive any right I may have to inspect hte finished product and I release The Seed Church and Camp Fearless from any liability for any use of the photographs or digital media.

I have read and am electronically signing this consent form as the legal guardian

yes no

Signature

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Camp Fearless 2024 - Student Registration

Description

Please Fix the Following