Child #1's Name *

First Name

Last Name

Child #1's Birthday *

MM

DD

YYYY

Child #1's Gender *

Boy

Girl

Child #1's Roommate/Leader Request

List only ONE person. If another camper, request MUST be mutual (the requested camper must request in return to be guaranteed).

First Name

Last Name

Child #2's Name

First Name

Last Name

Child #2's Birthday

MM

DD

YYYY

Child #2's Gender

Boy

Girl

Child #2's Roommate/Leader Request

List only ONE person. If another camper, request MUST be mutual (the requested camper must request in return to be guaranteed).

First Name

Last Name

Child #3's Name

First Name

Last Name

Child #3's Birthday

MM

DD

YYYY

Child #3's Gender

Boy

Girl

Child #3's Roommate/Leader Request

List only ONE person. If another camper, request MUST be mutual (the requested camper must request in return to be guaranteed).

First Name

Last Name

Parent/Guardian 1 Name *

First Name

Last Name

Parent/Guardian 1 Phone Number *

(###)

###

####

Parent/Guardian 2 Name

First Name

Last Name

Parent/Guardian 2 Phone Number

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Release and Liability Waiver *

By registering and typing my name below, I, the undersigned parent/guardian of the above listed minor(s), do hereby give full authority to Faith Community Church staff to authorize emergency medical treatment as is necessary in their judgment. I hereby release the staff from claims, which may arise from their good faith exercise of this authority. In case of an emergency, when neither my family physician or I can be reached, Faith Community Church has my permission to take my child to the emergency room of the nearest available hospital. The hospital staff has my permission to provide all the medical treatment that a physician deems necessary for the well being of my child. I do hereby release and agree to hold free and harmless Faith Community Church, its agents, officers, employees, and volunteer staff of any and all liability or responsibility in the event of personal injury sustained by my child, or damage to property of others caused by my child’s participation in Faith Community Church activities conducted at their facility. I also understand that photo and or video images will be taken during Camp Faith, and that the images will not be sold and children’s identity will remain anonymous and therefore give permission to Faith Community Church to use photo/video images for promotional purposes.

First Name

Last Name