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Middle School Camp on Monday, June 12, 2017 @ 8:30 AM

450.00
*Birthdate:
*Gender:
*Grade Entering Fall 2017:
Campus:

*Parent/Guardian's Full Name:
*Parent/Guardian's Email:
*Parent/Guardian Phone Number:
*Are you the parent or the guardian of the camper?

Please list a backup emergency contact for the week of camp that is not the student’s parent/guardian. We will always contact the parent/guardian first.
*Emergency Contact Name (First & Last):
*Emergency contact relationship to student:
*Emergency Contact Phone Number:

T-shirts will be available for purchase at check-in; let us know your adult t-shirt size so we can order them accordingly.
T-shirt size:
Please list up to two names of any roommate preferences:

*Does your student have any medical conditions we need to be aware of?
If yes, please explain:
*Does your student have any dietary restrictions?
If yes, please explain:
*Does your student carry an EpiPen?
If yes, please explain:
*Does your student carry a rescue inhaler?
If yes, please explain:

Liability Release Form:

The participant (or parent/guardian if participant is a minor) acknowledges and accepts the risks of physical injury that could occur with the participation in the activity described above. Except for gross negligence on the part of Granger Community Church, the participant (or parent/guardian) accepts personal financial responsibility for any bodily or personal injury sustained during the activity. Further, the participant (or parent/guardian) releases and agrees to hold harmless Granger Community Church and its representatives from any liability, injury, damage loss, accidents, delay or irregularity related to the undersigned individual’s planned participation in the activity.

The participant (or parent/guardian if participant is a minor) also assigns to Granger Community Church the rights to any photos, videotape and/or sound recordings made of me by or for Granger Community Church. I hereby authorize the reproduction, sale, copyright, exhibition and/or distribution of said photos, videotapes or sound recordings without limitation or compensation.

*By typing my name in this box I am acknowledging my signature: