Intermediate Camp 2024

Church Information

Student Information

Student First Name

Student Last Name

Date of Birth

Address

Parent Information

Parent First Name

Phone

Parent Last Name

Parent Email

Authorized Pick Up

Please enter up to two people authorized to pick up your student. If the parent/guardian listed above is one of them then their information must be entered below as well.

Authorized Pick-up #1

Authorized Pick-up #2

Driver's License/State ID

I understand only the persons listed above may pick up my student. NO EXCEPTIONS!

I understand that the ID listed above must be shown to pick up my student

Medical Information and Waiver

Emergency Contact

Insurance Provider

Emergency Contact Phone

Insurance Phone No

Insurance Policy No

Insurance Subscriber Name

Insurance Group No

Insurance Subscriber DOB

Allergies

List all food allergies

List all environmental allergies

List all medical allergies

Medications

List all medications

List all physical activities that your student cannot participate in

I understand all medications must be turned in to medical staff who will administer medications to my student

I give permission to camp medical staff to administer medication to my student as needed

Waivers and Releases

2024 Camp Rules

2024 Photo Use Agreement

Camp Waiver and Release Form

The forms Camp Rules, Photo Use Agreement, and 2024 Camp Waiver and Release have been made available to me and I agree to all terms and conditions.

A $25 deposit is required to reserve the current registration price. I may pay the full registration and receive a refund minus $25 if I cancel by May 18th. The $25 deposit is non-refundable and non-transferable.

Registration includes an off-site trip to swim at the YMCA. I must contact the camp director at impactetx@gmail.com if I want my student exempted from this trip.

I agree to receive SMS text updates and information regarding camp 2024.

Parent signature

I agree to the above terms and conditions