Summer Camp 2023
Group Registration

Student Information

Student First Name

Student Last Name

Date of Birth

Address

Parent Information

Parent First Name

Phone

Parent Last Name

Parent Email

Church Information

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

Insurance Policy No

Insurance Subscriber Name

Emergency Contact Phone

Insurance Phone No

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

Click to view camp rules

A copy of the camp rules has been made available to me and I agree to comply to all terms and conditions

Camp Liability Waiver and Release Agreement In consideration of the acceptance of my application for the Impact East Texas Camp program, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to my child as a result of their participation in said camp program. This release is intended to discharge in advance the East Texas District of the Pentecostal Church of God, its officials, officers, employees, volunteers, and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release, and assumption of risk is to be binding on my heirs and assignees. Consent of the Parent or Guardian I give consent for my child to participate in the summer program, and I execute the above liability release on my child's behalf (for children under 18) or my own behalf (for students 18 or older). I have read and understood the foregoing registration liability release and parental consent form and agree to all terms and conditions.

Parent signature or Student signature if 18 or over

I agree to the above terms and conditions

Date signed

Thanks for submitting!

Summer Camp 2023 Group Registration