FORM – 2021 Camps – Recreation Outreach Center

2021 Camps
Child Name*
First Last
Child Birthday*
MM slash DD slash YYYY
Child Grade being COMPLETED*
Child Notes (any information we should know?)
Does this participant have: any disabilities, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant condition?*
If yes, please state the condition*
Church (if you regularly attend, which one?)
Contact Email*
Father/Guardian Name*
Father/Guardian Phone Number*
Mother/Guardian Name*
Mother/Guardian Phone Number*
If you wish to have your family doctor contacted in case of emergency, what is his/her name?*
Family doctor phone number:*
EMERGENCY AUTHORIZATION
I, the undersigned parent or legal guardian of the participant, a minor, hereby authorize the camp leaders or parents of the players acting in the capacity of activity supervisors/vehicle drivers, as my Agents, to consent to medical, surgical or dental examination and/or treatment. In case of emergency, I hereby *
- Authorize – Emergency
Parent/Guardian Name*
First Last
PhoneParent/Guardian phone number*
Parent/Guardian Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Waiver of Liability and Disclaimer and Contract for Permission to Photograph
I, the parent or guardian of the above named individual, acknowledge that participation in athletic events necessarily involves risk of physical injury. I further acknowledge that the programs of the IBC Camp(s) and Immanuel Baptist are primarily administered by individuals who volunteer their time rather than paid professionals. In consideration for accepting the registration of the above name individual and permitting the voluntary participation of said individuals in its program, I hereby release, discharge, and hold harmless the IBC Camp, its employees, Immanuel Baptist, volunteers and other representatives from any claims arising out of relation to any physical injury that may result to said individual while participating in the ROC Summer Camp(s) sponsored event, including any physical negligence of an official, referee or coach while performing his/her duties during any practices, games or camps. I hereby grant permission to the ROC, a department of Immanuel Baptist Church, to use my photograph for the IBC Camp(s).
- Authorize – Waiver of Liability
Product Name
K-5 Grades (9:00am – 12:00pm EST)
- October 16 – Flag Football
- October 30 – Basketball
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Supported Credit Cards: American Express, Discover, MasterCard, Visa
Card Number Expiration Date Security Code Cardholder Name

2021 Camps

EMERGENCY AUTHORIZATION

Waiver of Liability and Disclaimer and Contract for Permission to Photograph

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