Enrollment Form


All Applications - Due Sunday July 2nd 2017

July 13, 14, 15, - 2017  9 A.M. - 4 P.M.

July 13, 14, 15, - 2017

 9 A.M. - 4 P.M.

The information that is provided by this form is gathered to assist us in identifying appropriate care for those who attend camp in case of medical emergency.  Those representing the camp in an official capacity at all events have the right to refuse any attendees who do not provide this information before or during registration for a particular event or activity. $35 Payment 

PARTICIPANT INFORMATION
Name *
Name
Date of Birth *
Date of Birth
(Copy of last report card required)
Gender *
Address *
Address
Phone *
Phone
EMERGENCY CONTACT
Name *
Name
(Listed Above)
Phone *
Phone
(Phone, Email, Etc.)
INSURANCE INFORMATION
Is The Participant Covered By Family Medical/Hospital Insurance *
Carrier Address *
Carrier Address
(Seizures, Diabetes, Low Blood Sugar, Heart Problems, Asthma, Etc.)
DISCLAIMER
By registering, I give permission for my child to participate in this program sponsored by Trinity Episcopal Church. I fully understand that his/her participation may entail the risk of physical injury. I agree to waive any claim of any kind whatsoever, whether resulting from an injury or otherwise, and further agree to release, indemnify, and hold harmless the program, Trinity Episcopal Church, and their respective directors, officers, employees, agents and/or representatives from any and all liability occurring as a result of his/her participation in the program. I will be personally responsible for any financial costs incurred because of his/her participation and/or medical expenses incurred as a result of any injury. Furthermore, I understand that Trinity Episcopal Church assumes no liability for lost, misplaced, stolen, and/or damaged property and I hereby agree to release Trinity Episcopal Church from such liability. Your child may have his/her picture taken during this year’s VBS week at Trinity Episcopal Church. These pictures may be used for the closing ceremony photo slide show, internet photo albums, and/or church flyers or brochures.