VBS Detailed Registration Camper Form 2021

Camper Information

Camper's Name

First Name Last Name

Birth Date

Month Day Year

Grade

Gender

Male Female

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country

Parent/Guardian Information

Name

First Name Last Name

Home Number

Area Code Phone Number

Cell Number

Area Code Phone Number

E-mail

Emergency Information

Emergency Contact's Name

First Name Last Name

Relationship

Phone Number

Area Code Phone Number

Alt. Phone Number

Area Code Phone Number

Does the camper have any allergies, food sensitivities, or medical conditions? If yes, please describe.

Is the camper prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by St. Matthew's Episcopal Church during the selected camp. In exchange for the acceptance of said child’s candidacy by St. Matthew's Episcopal Church, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless St. Matthew's Episcopal Church and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against St. Matthew's Episcopal Churchincluding all volunteers, instructors, and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.

Medical Release and Authorization

As Parent and/or Guardian of the named camper, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to St. Matthew's Episcopal Church and its affiliates including Directors, volunteers, and VBS Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered camp.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

St. Matt's VBS Camper Registration