Back to School Bash • Berean Baptist Church

Date & Time

August 12, 2022 6:00 PM - August 13, 2022 2:00 PM

Type

Price

Quantity

Male B2SB Registration

17 Remaining

Price
$30.00

Quantity
Female B2SB Registration

12 Remaining

Price
$30.00

Quantity

Male B2SB Registration 0

Camper Information

First Name *

Preferred Name

Last Name *

Church Attend

Tip: Please list the church the camper attends.

Date of Birth *

School Grade *

Gender *

Mailing Address *

Mailing City *

Mailing State *

Phone Number

Mailing Zip Code *

Mobile Number *

Email Address *

Is this the Camper's Email? *

In case of an emergency and the parent/guardian cannot be reached, please notify:

Emergency Contact *

Emergency Contact's Phone Number *

Parent/Guardian Information

Father's Name *

Phone Number

Is this a . . .

Address if different from the campers

Mother's Name *

Phone Number

Is this a . . .

Address if different from the campers

Authorized Pick Up Information

Please list any individuals (other than those who are on this form) that have permission to pick up your camper:

Medical Information

Please list any and all medical conditions: *

Please list any and all medications taken regularly and reason for medication: *

Specific activities to be restricted: *

Other necessary information: *

Insurance Information

Is the above named person covered by the family medical/hospital insurance? *

Yes

Note: If yes, all of the proceeding insurance information is required.

Carrier or Plan Name

Group Number

Name of Policyholder

Insurance ID Number or Social Security Number of Policyholder

Relation of Policyholder

Signature Required

"The personal information and health history listed above is correct and complete, as far as I know. I hereby give permission to the medical personnel selected by the camp director or other camp personnel (hereinafter called "camp director") to order x-rays, routine tests and treatments, and to release any records necessary for treatment, referral, billing, insurance purposes, or related to transportation related to me or my child. In the event my child or I experience a medical emergency, and I cannot be reached, I hereby give permission to the physician selected by the camp director to hospitalize and secure proper treatment and order injections of medication, surgery, and anesthesia for myself or my child as named above."

"I also have read the general information section in this brochure with my camper, and we agree to comply with the dress and conduct regulations while at camp."

By typing your name below you and your camper agree to all the above statements and regulations.

Parent/Guardian Signature *

Consent and Release

All campers (or their parent/guardian if under the age of 18) must read, sign and date this waiver.

With full knowledge, I accept full responsibility for any injury or accident that may occur to myself or
my child while participating in Woodlands Baptist Camp activities. I give permission for my child to
participate in activities that occur at Woodlands Baptist Camp, a ministry of Berean Baptist Church. I
certify that my child is able to participate in all the activities and sporting events except those I have
listed on the Medical Form

Although Woodlands Baptist Camp has taken reasonable steps to provide equipment and skilled
employees so yourself or your child can participate in activities for which he/she may not be skilled
in, we do remind you that these activities are not without risk. Certain risks cannot be eliminated due
to our camp’s rural setting and without destroying the unique character of those activities. The same
elements that contribute to the character of these activities can be cause of loss or damage to your
property, accidental injury or illness or, in extreme cases, permanent trauma or death. We do not want
to frighten you or reduce your enthusiasm for these activities, but we do think it is important for you to
be informed and know in advance about inherit risks.

For promotional or marketing purposes, Woodlands Baptist Camp reserves the right to use any audio,
video, and/or photography of guests or campers participating at Woodlands Baptist Camp facilities.

I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL THE RISKS WHICH MAY BE ENCOUN-
TERED ON ALL ACTIVITIES OF THE CAMP, INCLUDING ACTIVITIES PRELIMINARY AND SUB-
SEQUENT THERETO. I, on behalf of myself, my children, my assigns and my estate, do hereby
agree to hold Woodlands Baptist Camp and/or Berean Baptist Church, and its agents, employees,
and volunteers harmless from, and to indemnify for, any and all liability, actions, causes of actions,
claims, expenses, including attorney’s fees, and damages on account of injury to my child, even injury
resulting in death, which I now have or which may arise in the future in connection with my child's
participation in the activity and any other associated activities. I further agree to hold Woodlands
Baptist Camp and/or Berean Baptist Church, and its agents, employees, and volunteers harmless
from, and to indemnify for, any and all liability, actions, causes of actions, claims, expenses, including
attorneys fees, and damages on account of injury to a Third Party or his property which may arise in
the future in connection with my chiId’s participation in the activity and 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 Georgia 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.

By signing this document, I acknowledge that if anyone is hurt or property damaged during my or my
child’s participation in these activities, I and/or my child may be found by a court of law to have waived
any right to maintain a lawsuit against Woodlands Baptist Camp and/or Berean Baptist Church on the
basis of any claim which has been released herein. I have had sufficient opportunity to read this entire
document. I HAVE READ THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF
AND SIGN THIS RELEASE AS MY OWN FREE ACT. This is a legally binding agreement that l have
read and understand.

By typing your name below you agree to all the above consent and release information on behalf of the camper, parents and/or guardians.

Parent/Guardian Signature *

Date *

Female B2SB Registration 0

Camper Information

First Name *

Preferred Name

Last Name *

Church Attend

Tip: Please list the church the camper attends.

Date of Birth *

School Grade *

Gender *

Mailing Address *

Mailing City *

Mailing State *

Phone Number

Mailing Zip Code *

Mobile Number *

Email Address *

Is this the Camper's Email? *

In case of an emergency and the parent/guardian cannot be reached, please notify:

Emergency Contact *

Emergency Contact's Phone Number *

Parent/Guardian Information

Father's Name *

Phone Number

Is this a . . .

Address if different from the campers

Mother's Name *

Phone Number

Is this a . . .

Address if different from the campers

Authorized Pick Up Information

Please list any individuals (other than those who are on this form) that have permission to pick up your camper:

Medical Information

Please list any and all medical conditions: *

Please list any and all medications taken regularly and reason for medication: *

Specific activities to be restricted: *

Other necessary information: *

Insurance Information

Is the above named person covered by the family medical/hospital insurance? *

Yes

Note: If yes, all of the proceeding insurance information is required.

Carrier or Plan Name

Group Number

Name of Policyholder

Insurance ID Number or Social Security Number of Policyholder

Relation of Policyholder

Signature Required

"I also have read the general information section in this brochure with my camper, and we agree to comply with the dress and conduct regulations while at camp."

By typing your name below you and your camper agree to all the above statements and regulations.

Parent/Guardian Signature *

Consent and Release

All campers (or their parent/guardian if under the age of 18) must read, sign and date this waiver.

For promotional or marketing purposes, Woodlands Baptist Camp reserves the right to use any audio,
video, and/or photography of guests or campers participating at Woodlands Baptist Camp facilities.

By typing your name below you agree to all the above consent and release information on behalf of the camper, parents and/or guardians.

Parent/Guardian Signature *

Date *