Full Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Phone

(###)

###

####

Can you swim?

Yes

No

Not well

Name *

First Name

Last Name

Phone *

(###)

###

####

Physicians phone

(###)

###

####

Non food related allergies

Yes

No

Dietary Needs *

We want everyone to feel happy and well-fed, AND ALSO, please make it as easy on us as possible, only choosing what is necessary for your well-being, thanks!

None (Anything Goes)

Vegetarian

Pescatarian

Vegan

Gluten-Free

Lactose Intolerant

Other (please describe below)

*

If I become ill or involved in an accident, I authorize a Director of Adventure Camps or any other adult staff member to act on my behalf. They may approve whatever non-emergency or emergency treatment is necessary, and are authorized to sign any medical release or required form on my behalf. As soon as practicable, the listed emergency contact will be contacted in case of an emergency. I also agree to pay any necessary expenses incurred in the medical treatment of myself including, but not limited to, all transportation costs to and from a medical facility, and if necessary, transportation to my home or medical facility of choice.

*

All acts or omissions of the chaperones and staff shall not be considered acts or omissions of Adventure Camps or The Christian Community nor any of its local congregations. I hereby release The Christian Community in North America and of the Chicago region as well as the Adventure Camps staff from any liability. Under no circumstances will I seek to hold the staff, The Christian Community, or accompanying adults liable for any injury, accident, or incident affecting my well being.

*

If I break or damage any property as a result of my direct or indirect behavior, I hereby agree to pay for its repair or replacement. Adventure Camps, The Christian Community, its Board of Directors, and all of its employees, acting officially or otherwise, are hereby released from any and all claims, demands, actions, or causes of action, on account of any injury to myself that may occur subsequent to any unauthorized departure from the class or traveling group, or the presence of the chaperons. This release binds my heirs, executors, administrators, or assigns.

Photo Release *

I authorize Adventure Camps and/or The Christian Community to utilize my photographic images without identification in its brochures and advertisements in any media, including Adventure Camp’s and The Christian Community’s website. In giving my consent, I hereby release and hold harmless The Christian Community and its agents from any and all responsibility or liability relating to the use of the photographs. I understand that I will not receive compensation should any photograph authorized hereunder be used.

I do not authorize Adventure Camps or The Christian Community to utilize my photographic images.

Todays Date *

MM

DD

YYYY