Camper Registration

Please bring a completed Medical Form to camp with you.

Camper Information

Name

First Name

Last Name

Age

Birth Date

YYYY

Gender

Male

Female

Street Address

Street 2

City

State

ZIP

School

School You Attend

Church

Grade Completed

T-shirt Size

Important Health Information

Please include allergies, dietary needs, etc.

Promotional

I give permission for Oak Dale to use any photo and/or video of me or my family for promotional purposes.

Parent/Guardian Information

Parent Name

First Name

Last Name

Primary Phone Number

(###)

###

####

Alternative Phone Number

(###)

###

####

Email Address

Emergency Contact Information

Contact Name

First Name

Last Name

Contact Primary Phone

(###)

###

####

Contact Secondary Phone

(###)

###

####

Relationship to Camper

Permission

I do hereby waive and release any and all claims for damages, death, personal injury, loss of property, or property damage that I may have or that may subsequently accrue to me, or to my heirs, executors, administrators or assigns, as a result of my participation in Fusion – Youth Camp. I do further hereby discharge and release in advance to Fusion, its employees, agents, representatives, and boards, without limitation, from any and all liability arising out of or connected in any way with my participation in Fusion – Youth Camp. We release Fusion staff, from all liability for any injury related to participation in directed camp activities. I give Fusion – Youth Camp permission for me (or my child) to be transported to and from activities.

I have read and understand the above