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Home
About
Volunteer
Staff
Immanuel Baptist Church
Services
Biggest Loser
Group Fitness
Personal Training & Fitness Coaching
Classes
Memberships
iSPORTS
Our Facilities
Contact
How Can We Pray?
Menu
Home
About
Volunteer
Staff
Immanuel Baptist Church
Services
Biggest Loser
Group Fitness
Personal Training & Fitness Coaching
Classes
Memberships
iSPORTS
Our Facilities
Contact
How Can We Pray?
Facebook
Envelope
2021 Camps
Child Name
*
First
Last
Child Birthday
*
MM slash DD slash YYYY
Child Grade being COMPLETED
*
Kindergarten
1st
2nd
3rd
4th
5th
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?
*
Yes
No
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
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bonaire, Sint Eustatius and Saba
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos Islands
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d'Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini (Swaziland)
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard and McDonald Islands
Holy See
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Réunion
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia
South Korea
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen Islands
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
US Minor Outlying Islands
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
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
Month
01
02
03
04
05
06
07
08
09
10
11
12
Year
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
Expiration Date
Security Code
Cardholder Name
New Prices - starting July 1st
We will be slightly increasing our prices starting on July 1, 2022. Please note the following changes:
Walkers Only – $60
Walkers Senior Only – $50
Walkers Only Monthly – $6
Walkers Senior Only Monthly – $5
Full Access – $100
Full Access Senior Only – $90
Full Access Monthly – $10
Full Access Senior Only Monthly – $9
Family Plan – $220
Family Plan Monthly – $20
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