Camp Registration 11 2009

YOUTH CAMP REGISTRATION: Name: _________________________________ Nickname: _________________________________ Birth Date: ____ /____ /______ Age: ____ Male: ___ Female: ___ Address: _________________________________ _________________________________ _________________________________ Telephone Number: _________________________________ Emergency Number (s): _________________________________ _________________________________ Parent (s) Names: _________________________________ _________________________________ Parent Email and Phone Number: ___________________________________ _______________________________ Things to Bring: Bible Sleeping Bag/Sheets Pillow Towel Toiletries Pen & Paper AN OPEN MIND No Drugs or Alcohol is allowed!

I, the undersigned parent and/ or guardian of the child, whose name appears below (hereinafter known as “Participant”), hereby give my consent for the delegate to attend the Couples for Christ-Youth for Christ Camp on November 6 to November 8, 2009 at the Sacred Heart Center. The undersigned hereby understands that the Sacred Heart Center is a privately owned facility and is covered by its own premise and general liability and/or responsibility, which is not covered under the policy, held by the mentioned facility. The undersigned hereby understands that each of the delegates will be provided constant adult supervision. All the participants must be able to follow directions, guidance, and instructions in a proper manner at all times. By signing below, I am certifying that my child is well behaved, responsible, willingly accepts all rules and regulations and follows instructions and directions. I hereby authorize Couples for Christ-Youth for Christ to arrange for my child’s medical attention, diagnosis, treatment, and hospitalization and care in care of emergency call, after an unsuccessful effort has been made to contact the undersigned representative. Couples for Christ-Youth for Christ is therefore fully absolved and released from any responsibility and/or liability for my child while engaged in any of the activities within the scope of the program. I agree and understand that I hold harmless, Couples for Christ-Youth for Christ from all or any liabilities, costs, or damage to any property caused by or arising out of my child’s participation in this camp.