Camper's Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Birthdate *

MM

DD

YYYY

Gender *

Select one

Male

Female

Christian *

Select one

Yes

No

Emergency Contact #1 *

First Name

Last Name

Phone #1 *

(###)

###

####

Emergency Contact #2 *

First Name

Last Name

Phone #2 *

(###)

###

####

Physician

First Name

Last Name

Physician's Phone

(###)

###

####

T-Shirt Size: *

XS

S

M

L

XL

ACKNOWLEDGEMENT OF RISK: I have read the Acknowledgement of Risks Notice linked above. *

Yes

I freely and voluntarily assume the risks/hazards inherent in the program/activity and understand and acknowledge that my child may suffer personal and potentially serious injury arising from his/her participation. *

Yes

My child has been informed that he/she is to abide by the rules and regulations, including directions and instructions from CEBC Camp leaders over all phases of the program/activity. *

Yes

I acknowledge that it is my duty to advise CEBC Camp Leaders of any medical/health concerns of my child that may affect his/her participation. *

Yes

I acknowledge that CEBC may choose to cancel the trip if travel conditions are deemed unsafe (eg weather, health advisory). I accept that CEBC will not be liable for any costs associated with such a cancellation. *

Yes

I acknowledge that the Camp Leaders may secure transport to emergency medical services as they deem necessary for my child’s immediate health and safety, and that I shall be financially responsible for such services. *

Yes

SWIMMING ACTIVITY CONSENT: I give permission for my child to participate in swimming activities. *

Yes

No

If yes, my child's swim level is:

Beginner

Intermediate

Advanced

CANOE ACTIVITY CONSENT: I give permission for my child to participate in canoeing/kayaking activities. *

Yes

No

MEDIA CONSENT: I authorize Cornerstone Evangelical Baptist Church the right and permission to publish, reproduce, or otherwise use for promotional purposes the camp participant’s name, voice, and likeness in photographs, written materials, and audio-visual recordings. *

Yes

No

COVID-19 LIABILITY RELEASE: I acknowledge that any activity involving multiple participants comes with the risk of contracting COVID-19 (Coronavirus disease) or other infectious diseases. By submitting this online registration form, I agree that I will not hold Cornerstone Evangelical Baptist Church liable for any COVID-19 infection that may occur before, during, or after participation in this camp. *

Yes

CAMP CONSENT/LIABILITY RELEASE: By submitting this online registration form, I hereby give my consent for the above named registrant to attend the camp held by Cornerstone Evangelical Baptist Church from Sunday, August 18, 2024 to Thursday, August 22, 2024, and also release Cornerstone Evangelical Baptist Church from any liabilities which may arise concerning my child’s participation in the camp. *

Yes