2021 Summer Slam Camper Registration If you are a human and are seeing this field, please leave it blank. Fields marked with an * are required First Name * Last Name * Gender * Age * Birthdate * Address 1 * Address 2 * City * State * Alabama Alaska Arizona Arkansas 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 Zip / Post Code * Parents Name? * Email * Phone for contact and emergencies * Select your child's t-shirt size: * Small Medium Large XL 2X 3X Does your child need transportation to and from Calvary Community Church? * Yes. Yes, but on certain days. No. Please list all allergies. My student one of these issues: Asthma, Heart problems, Epilepsy, or Diabetes. If you checked the box above, please describe your students issue: I UNDERSTAND: Our camp fee does not include the cost of medical treatment. The health coverage provided by the camp is secondary coverage. Your insurance must be billed first, and you must be ready to pay for any medical expenses in full when you pick up your child. Your insurance, and then our insurance, will make payment to you. We will not seek medical services without prior consultation except in the case of an emergency. * I AGREE: In case of emergency, I give permission for the Camp Nurse (selected by the camp director) to give my child over the counter medicine(s) for minor ailments (headaches, stomachache, insect bites, sore throat, etc.). I also give permission for my child (as named above) to be transported to, and treated at, the nearest medical facility in the event of an emergency. * CONTENT AND RELEASE: I, the undersigned parent, or guardian, hereby consents to my child participating in Tampa Youth Ranch Summer Slam at Calvary Community Church 4811 George Rd Tampa, FL 33634 on July 15th – 17th, 2021. This includes the transportation of my child to and from each location. I certify that my child is able to participate in all activities except . If my child has medical conditions, which may be relevant to a physician in the event of an emergency, I have listed them on the health form. In the event an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached, I hereby authorize (an adult sponsor) to make emergency medical decisions for my child. I understand and hereby agree to assume all of the risks, which may be encountered on said activity, including activities preliminary and subsequent thereto. I do hereby agree to hold Calvary Community Church 4811 George Rd. Tampa, Fl. 33634, and its agents harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which I now have, or which may arise in the future in connection with the activity or participation in any other associated activities. I expressly agree that this release waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of Florida and that if any portion thereof is held invalid, it is agreed that the balance shall notwithstanding continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital. I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release as my own free act. This is a legally binding agreement, which I have read and understand. * Please list any activities your child is not allowed to participate in (i.e. swimming, canoeing, physical games, etc.) I understand that my child MUST ATTEND Day One and Day Two in order to go to Busch Gardens on Day Three. * I understand that a payment of $70 via paypal will be required to complete the registration of my child for the 2021 Summer Slam. * SIGNATURE OF PARENT/GUARDIAN * DATE OF FORM COMPLETION * If you are a human and are seeing this field, please leave it blank.