REG FORM- York, SC Please fill out the form below to register for camp.RM_StatsPersonal InformationEmail *Enter email again *First Name *Last Name *Gender * Male Female Birth Date *T-Shirt Size:Select an optionSMLXL2XL3XLContact InformationMailing Address: State or Region AL AK AZ AR AA AE AP CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Home Church:Pastor:Emergency ContactAll participants, including adults, are required to provide at least 1 emergency contact.Name: *Relation to Participant: *Select an optionMotherFatherLegal GuardianFamily MemberSpouseOtherCell Phone Number *Home Phone Number:Workplace:Work Phone:Health InsuranceHealth Insurance Company: *Policy Number: *Mailing Address: Address Line 1 * Address Line 2 City * State or Region Alabama Alaska Arizona Arkansas Armed Forces America Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming State or Region * Zip * Agent Name:Phone Number: *Insurance CardPlease upload a copy of both the front & back of your insurance card.Medical InformationKnown Allergies: *Let us know if you have any known food, drug, or environmental allergies, or say "N/A".Do you need meal options that accommodate a food allergy? * Yes, I have a food allergy and have listed it in the previous question. No, I do not have a food allergy. Recent Injury/Illness: *Let us know if you have any recent injury or illness that may impact your participation at camp, or say "N/A".Notable Health Conditions: *Let us know if you have any health conditions that camp staff should be made aware of, or say "N/A".Date of last Tetanus Booster: *Please enter the month and year.Legal FormsPlease be aware, Camp One Fifty One involves activities that carry certain risks. These risks include, but are not limited to, the use of power tools, ladders, nail guns, exposure to electrical hazards, as well as normal household hazards.Consent for Participation, Release of Liability, and Indemnification Agreement: *We hereby give approval for the undersigned participant to attend and participate in Camp One Fifty One during the current year. In consideration for me or my youth participant being allowed to participate in this activity, I/we, for myself/ourselves and on behalf of my/our child, knowingly and freely assume all risks and hazards related to Camp One Fifty One activities including but not limited to, transportation to and from camp, churches, and homesites. Even if arising from the negligence of those entities and persons released from liability below, and assume full responsibility for participation in Camp One Fifty One. Further, I/we for myself/ourselves and on behalf of my/our heirs, do hereby release, discharge, and hold harmless Liberty Church of York, SC and its Trustees, officers, employees, and agents, as well as the organizers, sponsors, supervisors, counselors, chaperones, and other support staff persons for Camp One Fifty One (collectively referred to hereinafter as "Releasees"), with respect to any loss, injury, or other damage to me/us and my/our child arising out of or in any way related to activities at Camp One Fifty One including, but not limited to, transportation to/from the camp, churches, and home sites, whether caused by the negligence of the releases or otherwise, except that which is the result of gross negligence and/or willful and wanton misconduct. I/we further agree to indemnify and hold harmless the Releasees from any clams, losses, injuries, or other damages related to our arising from the undersigned participant's attendance or participation in Camp One Fifty One including, but not limited to, any claims submitted on behalf of the participant. I/we have read this release of liability and assumption of risk agreement, fully understanding its terms, understand that I/we have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.I accept.Consent for Participation, Release of Liability, and Indemnification Agreement: *We hereby give approval for the undersigned participant to attend and participate in Camp One Fifty One during the current year. In consideration for me or my youth participant being allowed to participate in this activity, I/we, for myself/ourselves and on behalf of my/our child, knowingly and freely assume all risks and hazards related to Camp One Fifty One activities including but not limited to, transportation to and from camp, churches, and homesites. Even if arising from the negligence of those entities and persons released from liability below, and assume full responsibility for participation in Camp One Fifty One. Further, I/we for myself/ourselves and on behalf of my/our heirs, do hereby release, discharge, and hold harmless Liberty Church of York, SC and its Trustees, officers, employees, and agents, as well as the organizers, sponsors, supervisors, counselors, chaperones, and other support staff persons for Camp One Fifty One (collectively referred to hereinafter as "Releasees"), with respect to any loss, injury, or other damage to me/us and my/our child arising out of or in any way related to activities at Camp One Fifty One including, but not limited to, transportation to/from the camp, churches, and home sites, whether caused by the negligence of the releases or otherwise, except that which is the result of gross negligence and/or willful and wanton misconduct. I/we further agree to indemnify and hold harmless the Releasees from any clams, losses, injuries, or other damages related to our arising from the undersigned participant's attendance or participation in Camp One Fifty One including, but not limited to, any claims submitted on behalf of the participant. I/we have read this release of liability and assumption of risk agreement, fully understanding its terms, understand that I/we have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.I accept.Signature: Note: It looks like JavaScript is disabled in your browser. Some elements of this form may require JavaScript to work properly. If you have trouble submitting the form, try enabling JavaScript momentarily and resubmit. JavaScript settings are usually found in Browser Settings or Browser Developer menu.
