CAMP JR FORM

Camp Jr Form

* Indicates required field

Child's Name *

First

Last

Child's Age *

Gender *

Male Female

Grade entering Fall 2018: *

EMAIL *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Check the applicable catagory:

Select Shirt Size for Child *

Mother's Name *

First

Last

Phone Number *

Father's Name *

First

Last

Phone Number *

Emergency Contact Name *

First

Last

Relationship *

Phone Number *

Statement of Health for:

Child's Name *

Is there any information we should have regarding the welfare of this attendee; handicaps, restrictions, diets, etc? *

Yes No

If yes, please provide: *

Is there any activity you do not with him/her to participate in? *

Yes No

If yes, please provide: *

List anything your child is allergic to: *

List information concerning medications to be given while away from home: *

Is your child covered by insurance? *

Yes No

If yes, Insurance Company and Policy # *

Medical Consent: I do hereby state that I have legal custody of this child, a minor, who resides with me. While this minor is a registered camper at Camp Jr, I hereby authorize any director, staff member, nurse, dean, lifeguard, or other responsible person of said camp to consent to any x-ray, examination, anesthetic, medical or surgical treatment, and hospital care, to be rendered to this minor under the general or special supervision and on the advice of any physician or surgeon licensed to practice in the United States, when such medical or surgical treatment is necessary. I further understand that my personal health insurance will be the primary policy coverage in the case of accident or illness. Furthermore, if no personal health insurance policy information is provided by myself, I will be personally responsible for any medical charges incurred. I also give permission for my child to receive over-the-counter medication from the camp first aid station if necessary.

Required to proceed *

I agree

Discipline/Property Consent: I understand that Northridge will make rules and guidelines that my child will abide by while attending camp. I understand that if my child misbehaves and does not respond in a positive manner, I may be called to pick him/her up. Warnings will be given, but if inappropriate behavior continues, I will come and get him/her and no refund will be issued. In addition, I will pay for any damage that is done to the camp and/or to personal property belonging to another individual. I give permission to the camp director and/or assistant camp director to inspect the contents of any or all of my child’s personal belongings, and to withhold and/or dispose of any improper or illegal contents.

Required to Proceed: *

I Agree

Activity Consent: I give my permission for my child to participate in all camp-related activities. I understand by signing this release form, I am assuming such risks that are both known and unknown to me at the time.

Required to proceed: *

I agree

Promotional Consent: I consent to the use of any videotape, photographs, audiotapes, or any other visual or audio reproduction in which my child may appear by EDEG or Northridge. I release Northridge and/or EDGE from any liability connected with the use of picture or voice recording as part of any promotion, recruitment, or fund-raising program.

Required to Proceed *

I Agree

I (parent or guardian of student) agree to be present for dropping off my child at camp on AUGUST 3rd, 8AM, at PASTOR GARY'S HOME. *

I agree I am unable to drop-off my child in person

If you are unable to drop-off your child in person for camp, please contact Pastor Gary at gsmith@thenorthridgechurch.org .

Submit

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Encourage - Develop - Grow - Empower

EDGE is more than just a kid’s ministry
EDGE EXISTS TO BRING THE WORD OF GOD TO CHILDREN. WE STRIVE TO ENCOURAGE EVERY CHILD WITH THE HOPE OF SALVATION. WE WORK TO DEVELOP A DESIRE IN THE CHILDREN TO GET MORE FROM GOD. WE MAKE EVERY EFFORT TO HELP THEM GROW IN CHRIST AND EMPOWER THEM TO WALK AS EXAMPLES OF CHRIST.

Northridge Church
309 Wilkinson Ln.
White House, TN 37188
P:615-672-6789
F: (615) 772-1202

Pastor Gary Smith
gsmith@thenorthridgechurch.org

Camp Jr Form

Statement of Health for:

﻿Encourage - Develop - Grow - Empower﻿

Encourage - Develop - Grow - Empower