Registration for Grades 6-9 Step 1 of 6 - Basic Student Information 0% Are you an active member of a sponsoring church?* Yes Basic Student InformationPlease complete all of the basic student information fields.Full Name* First Middle Last Suffix Gender*Please SelectMaleFemaleDate of Birth* Month Day Year Age* School Name* Grade Completed by June of this year?*Please Select6789 T-Shirt Size*Please select a size choice. Youth Medium: (10-12) Youth Large: (14-16) Youth X-Large: (18-20) Adult Small Adult Medium Adult Large Adult X-Large Adult XX-Large Parent & Emergency Contact InformationPlease complete all of the parent & emergency contact information fields.Parent 1 - Name* First Last Parent 1 - Primary Phone Number*Parent 1 - Cell Phone Number*Parent 2 - Name* First Last Parent 2 - Primary Phone Number*Parent 2 - Cell Phone Number*Emergency Contact - Name* First Last Emergency Contact - Primary Phone Number*Emergency Contact - Cell Phone Number* Additional Contact InformationPlease complete all of the additional contact information fields.Email* Enter Email Confirm Email Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Additional Student InformationPlease complete all of the additional student information fields.Do any of the following health history related items apply to your student?*Please select all that apply. Allergies Chronic Asthma Diabetes Drugs Epilepsy Frequent Colds Frequent Stomach Upsets Heart Insect Stings Physical Handicap Other None of these apply If you selected any of the items above, please explain each in detail below.*(i.e. include normal treatment of allergic reactions) Name of student's Doctor* Phone Numer of student's Doctor*Do you have health insurance?*Please SelectYesNoOur church’s insurance is only secondary insurance. If you have medical insurance, you carrier will be billed for medical charges in the case of illness or injury while your student is on a church-related activity.Name of Insurance Company* Name of the Insured* First Last Insurance Policy Number* Insurance Company Phone Number*Does this student have any special needs, activity restrictions, or requirements which we should know?*Please SelectYesNoPlease explain your student's special needs, activity restrictions, or requirements:*Are there any special concerns or circumstances you would like your student's team leader to be aware of prior to your student's arrival at camp?*Please SelectYesNoPlease explain your student's concerns or circumstances:*Do you aknowledge that Champ Camp has permission to use any image of your student made with others at camp or any written material that he/she may write about camp for promotional purposes?* Yes List the name(s) of the individual(s) who have permission to pick up your student from camp at the end of each day:*Please list each name separated by a comma in the field below. Champ Camp MealsWe are blessed to have BAM/TMD Management, LLC as a partner for Champ Camp. Alongside our sponsoring churches, BAM/TMD Management, LLC is offering McDonald's meals, FREE OF CHARGE, to all campers. To better accommodate that process, we are asking each camper to register for these meals below.Monday- Chicken Sandwich, Chips, Apples, & Water* Yes No Tuesday- Hamburger, Chips, Yogurt, & Water* Yes No Wednesday- Cheeseburger, Chips, Apples, & Water* Yes No Thursday- Chicken Sandwich, Chips, Yogurt, & Water* Yes No Medical/Liability Terms & ReleasesPlease complete all of the medical and liability release fields.Medical Release Terms & Conditions*Please read Medical Release Terms & Conditions carefully and select "i agree" when you are finished.The Health History is correct so far as I know, and the person herein described has permission to engage in all prescribed activities except as noted. Emergency Authorization - I hereby give permission to medical personnel selected by the Champ Camp staff to order X-rays. routine tests, and treatment for myself. In the event of an emergency and neither my primary contact nor secondary can be reached, I hereby give permission to the physician selected by the Authorized Agent to hospitalize, secure proper treatment, order injections and/or anesthesia and/or surgery to myself as named above. I further authorize the release of the above medical information to appropriate medical personnel and/or the health coverage insurance company. In addition, I have, and do hereby, release the church, its employees or agents from liability associated with participation in Champ Camp. I understand that if I do not have medical insurance, I, as the parent or guardian, will be responsible for any medical expenses in the event of a sickness and/or injury. I understand that there are risks involved in taking place in recreation activities and other activities related to participation in Champ Camp. I agree to the Medical Release Terms & Conditions Liability Release Terms & Conditions*Please read the Liability Release Terms & Conditions carefully and select "i agree" when you are finished.I, the undersigned, will be participating in Champ Camp (hereafter the 'activity') at Emmanuel Baptist Church during the first week of June of 2022. I recognize that there are risks involved in participating in this activity and hereby assume all risk of injury, harm, damage, or death in connection with my participation in this activity. I understand and agree that neither Emmanuel Baptist Church nor its deacons, staff, employees, or volunteers may be held liable in any way for any injury, harm, damage, or death that may occur to my child as a result of his or her participation in camp activities. To the fullest extent permitted by law, I agree to save and hold harmless Emmanuel Baptist Church, its deacons, staff, employees, or volunteers from any claim by my child, myself, or other persons arising out of my child's participation in Champ Camp. I authorize Emmanuel Baptist Church through its deacon's, staff, employees, or volunteers to render or obtain such emergency medical care or treatment for my child as may be necessary should any injury, harm or accident occur to my child while participating in this activity. I agree to the Liability Release Terms & Conditions Signature* Reset signature Signature locked. Reset to sign again Please sign your full legal name using your mouse, track-pad, or finger and click submit below to complete the registration.Section BreakPhoneThis field is for validation purposes and should be left unchanged.
