Summer Smash Registration Form 2022

Student #1's Name

Student #2's Name

Student #3's Name

Phone

Address

Parent/Guardian Name

Parent/Guardian Email

This address will receive a confirmation email

Parent/Guardian Cell Phone Number

Emergency Contact Information

Attempts will be made to contact parents/guardians first.

Emergency Contact #1 Name

Emergency Contact #1 Cell Phone number

Emergency Contact #2 Name

Emergency Contact #2 Cell Phone number

Medical Information

Insurancy Company

Policy #

Policy Holder's Name

Policy Holder's Date of birth

May over the counter medications be given to your student by adult volunteers?

Yes No

Student Allergies

Special Diet

Special Needs/Medication Information

Payment

The cost is $250 per student and includes room, food, and activities. A $100 camp voucher is available for all students, making the cost of Summer Smash only $150!

RELEASE, WAIVER, AND INDEMNIFICATION AGREEMENT

Please Read and Sign Electronically

I acknowledge that participation in retreat activities involves risk to my student and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration of the opportunity to participate in retreat activities, I acknowledge and accept the risks of injury associated with my student’s participation in retreat activities and transportation to activities, if applicable. I accept personal financial responsibility for any injury or other loss sustained during the retreat or during transportation to activities. As well as for any medical treatment Grace Community Church authorizes rendered to my student or its employees, volunteers, or any other representatives. Further, I release and promise to indemnify, defend and hold harmless Grace Community Church for any injury arising directly or indirectly out of retreat activities or transportation to activities, if applicable, whether such injury arises out of the negligence.

Electronic Signature

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Description

7/28 - 8/1/22

Please fill out this form and click submit.

Summer Smash Registration Form 2022

Description

Please Fix the Following