Online PA Day Camp Registration

Boomerang P.A. Day Camp Registration Form 2019/2020

Harmony Baptist Church is collecting and retaining this personal information for the purpose of enrolling your child in Boomerang Day Camp. This information will be maintained permanently, as it is a requirement of our insurance company and legal counsel. If you wish Harmony Baptist Church to limit the information collected, or to view your child's information, please contact us.

Camper Information

* Indicates required field

Name *

First

Last

Birthdate *

Full Address *

Health Card # *

Contact Information

#1 Parent/Guardian Name *

First

Last

Phone Number *

Email *

#2 Parent/Guardian (Optional) *

First

Last

Phone Number *

Email *

Alternate Emergency Contact Name *

First

Last

Phone Number *

More Camper Information

Please list any allergies or medical conditions and any prescribed medications such as inhalers, Epi Pens. *

Please list any dietary restrictions. *

Extended Care *

Before Care Required After Care Required

Please read the information below before submitting the registration form.

I understand that this is a legal agreement and by submitting the registration form, I freely understand and accept that I am giving up certain legal rights. I am aware of and agree to allow my child to participate in the indoor and outdoor activities as part of the day camp. I understand that there are risks involved with participating in indoor and outdoor games and that injury could result. I freely and fully accept all risks, damages, dangers and hazards, and the possibility of personal injury.

In the event of an emergency, I understand that it may be necessary to obtain medical treatment/administer first aid and/or transport my child to a medical facility and hereby grant my consent to Harmony Baptist Church to transport my child to the nearest medical facility and assume full liability for any costs related to the treatment and transportation of my child.

I hereby release, indemnify, and hold harmless Harmony Baptist Church and its directors, corporation members, staff, agents, volunteers, members and representatives from: a) any personal injury, accident or damage to the above named child or his/her property; b) any claims, demands, actions and costs for any loss, injury, damage or expense whatsoever that might arise due to the above named child’s participation in the activities; and c) any and all liability for any damage to the personal property of or personal injury to, any third party resulting from the above named child’s participation in the activities.

I understand that this is a legal agreement that is bound upon my heirs, executors, my administrators, successors, assigns, and myself. I acknowledge that I have read and understand the terms of this agreement and acknowledge that by submitting this form I am voluntarily agreeing to abide by its terms and conditions and I am waiving certain legal rights that my child or I may have.

Name of person submitting this form *

Submit and Pay