Youth Registration Form | South Seaville Camp Meeting

Step 1-Complete the Form Below for Each Young Person

Step 2-Submit Online Payment for Each Young Person You are Registering.

ex: $10 for 1 person, $20 for 2 persons, $30 for 3 persons, etc.

Student Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Parent/Guardian Home Phone *

Home Phone

Parent/Guardian Work Phone *

Work Phone

Other Contact Home Phone

Home Phone

Other Contact Work Phone

Work Phone

Parent/Guardian Email *

Medical Info

Doctor's Name *

Doctor's Phone *

Insurance provider *

Policy number *

Medical Information *

Medical Information and/or Restrictions (e.g. allergies, carries inhaler, etc.) If there are none, entered NONE in this section.

Granting Permission

I believe that South Seaville Camp Meeting Association (SSCMA) is providing adequate supervision for this event, but I understand that participation of my child at this event is at my own risk. I consent to participation of my child and authorize the SSCMA Board of Directors or their designee/volunteers to take whatever reasonable steps (s)he deems necessary in order to provide emergency medical care for my child. I further agree to permit my child to be transported to a medical facility by ambulance or other commercial vehicle. I understand and agree that I will be responsible for all medical bills and costs that may be incurred as a result of medical care and treatment of my child.

Parent / guardian signature *

/s/________________________________________________________________________

Digital Signature Information: For your convenience you may now E-sign this document by checking the box below and typing your name on the signature line above. If you do not wish to use E-sign, simply print form, sign & print your name and send by email address above. Your typed E-signature along with the symbol /s/ is considered legal under the Federal E-Sign Act. Aer you check the box, click submit.

My Digital Signature is Printed Above *

Yes, I Grant My Permission.

File Upload

Click or drag a file to this area to upload.

If you wish you may print this form, sign it and upload it to us.

Additional Comments

Phone