Camp Hope

Part 1: Guardian Information

Name*

First Last

Relationship to Camper:*

Cell phone:*

Other Phone:*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email*

Second Guardian (Optional)

Name

First Last

Relationship to Camper:

Cell phone:

Other phone:

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email

We’d love to know how you heard about us!

Part 2: Camper Information

Name*

First Last

Gender*

Male
Female

Current Age:*

Date of birth:*

School Grade Entering this Fall:*

Directions: Please place a check mark next to the session(s) camper will attend.*

Health Information

Does the camper suffer from any allergies?

Severity of each allergy:*

Has the camper undergone any operations or sustained any serious injuries?

Is the camper currently taking any medications? If yes, please include the name of medication (brand name and generic name), dosage and reason below (we do NOT administer medication).

Please specify below any dietary restrictions, including vegetarian/vegan, lactose or gluten The Undersigned participant in Family Camp and his or her parent(s)/legal guardian(s) hereby agree as follows:

Terms and Conditions

Terms and Conditions*

I agree to the Terms and Conditions.

Terms and Conditions
My parent(s)/legal guardian(s) and I hereby agree that we will
adhere to all of the rules and regulations of Camp including without
limitations, the medical procedures established by the Camp.
My parent(s)/legal guardian(s) and I hereby understand that we
must have family medical coverage for me.
My parent(s)/legal guardian(s) and I hereby unconditionally release
the sponsoring Camp, and any of their officers, directors,
executives, employees, agents, volunteers and anyone working
under, through or in connection with any of them with respect to
any incident, claim, occurrence, loss, injury, or damage that could or
may arise out of such participation, including, by way of illustration
and not limitation, travel to, from, and within the country; home
hospitality; use of any and all facilities used for Camp or any part
thereof; social; cultural and other events and activities in which I
may participate or engage, whether or not the same may be
deemed to be a part of Camp or not, from the time when I shall
leave my permanent residence until the time when I shall have
returned thereto.

By signing below, my parent(s)/legal guardian(s), and I agree to the terms outlined above.

Print name of Parent/Guardian:*

First Last

Date

Relationship to Camper:*

Signature*

Health Declaration

Health Declaration*

I agree to the Health Declaration.

I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE STATE
OF “” THAT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF
MY CHILD IS IN GOOD PHYSICAL HEALTH AND IS CAPABLE OF
PARTICIPATING IN CAMP ACTIVITIES, GAMES & VIGOROUS PHYSICAL
ACTIVITY. I HEREBY AUTHORIZE MY CHILD TO PARTICIPATE IN SUCH
ACTIVITIES.
Illness, Accident, or Leaving Camp: In the event of serious illness or
injury I authorize emergency medical care for my child. I wish my
child to be taken to the nearest Emergency Medical Facility, and the
doctor listed below to be notified.
The parent or guardian of the child must provide and administer
any medication needed during camp.
If you have any question feel free to contact us.

Signature*

Print name of Parent/Guardian:*

Relationship to Camper:*

Date

Please register here:

Part 1: Guardian Information

Second Guardian (Optional)

Part 2: Camper Information

Health Information

Terms and Conditions

Health Declaration