Esperanza Summer Camp Registration 2018
To be filled out by parents or guardians of campers.
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Email *
I AM REGISTERING FOR: *
CAMPER'S FIRST AND LAST NAME *
CAMPER'S MAILING ADDRESS
CAMPER'S BIRTHDATE (month/day/year) *
MM
/
DD
/
YYYY
Where will you drop your kids off? *
MEDICAL NUMBER *
PARENT OR GUARDIAN'S NAME *
PARENT OR GUARDIAN'S PHONE NUMBER *
PARENT OR GUARDIAN'S E-MAIL ADDRESS *
EMERGENCY CONTACT NAME AND NUMBER *
ALLERGIES/MEDICAL CONDITIONS
Please list allergies, medical concerns, present prescriptions, problems with bedwetting, or any other information that would be beneficial for us to know about your child.
PICTURES *
Check the box that applies to you:
Required
Payment *
NOTE: You will receive a payment request form 2 weeks prior to camp. Please DON'T transfer a payment before then. Please indicate how you are planning to pay for camp so that we can send you the necessary instructions? If a Band is sponsoring your camper, please add the name of the Band in the "OTHER" box.
Required
CAMP WAIVER *
Type your name as an agreement.I, ______________________________________, am/are the parent(s) or guardian(s)
CAMP WAIVER *
(Please check all the boxes)
Required
I am/are the parent(s) or guardian(s) *
(Your name below.)
of ___________________________________________________, who is/are under the age of 19. I fully understand the risks and dangers involved in the programs and experiences offered at the facilities run by ESPERANZA MINISTRIES ASSOCIATION. In consideration of ESPERANZA MINISTRIES ASSOCIATION offering the programs and opportunities to the above named person(s), I agree to assume all risks involved. This release and assumption of risk is binding upon me, my heirs, executors, administrators and successors. *
(Camper's name below.)
I have read and clearly understand this liability release. I am at least 19 years old. Participant/Parent/Guardian’s Name *
(Please enter your name, the parent or guardian, as a signature.)
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