Clone of Camper Registration Form

1
Parent/Guardian Name* This field is required.Please give the full name of the parent/guardian who is filling out this form for campers.
First Name
Last Name
2
Relationship to the Camper
3
Parent or Legal Guardian Phone Number* This field is required.
Please enter a valid phone number.
4
Email* This field is required.
example@example.com
5
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
6
Emergency Contact* This field is required.
First Name
Last Name
7
Emergency Contact's Relation To The Camper* This field is required.
8
Emergency Contact Phone Number* This field is required.Please make sure this is a number that can be reached at all times.
Please enter a valid phone number.
9
Church Name & City (if attending with one)
Huge
Large
Normal
Small
Ok
Ok
10
Camper Name* This field is required.
First Name
Last Name
11
Upload a clear picture of the camper (no other individuals in photo):* This field is required.Camper's privacy will be protected and distribution of the image will not occur outside of camp liberty. This is for identification/safety purposes.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
12
Camper's Date of Birth* This field is required.
Date
Month
Day
Year
13
Age when attending camp:* This field is required.
14
Which Week of Camp is this camper registering for?* This field is required.
Junior Week 1 - Jethniel Wyler (June 22 - June 26)
Junior Week 2 - Davide Kim (July 6 - 10)
Teen Week 1 - Justyn Smith (June 29 - July 3)
Teen Week 2 - David Sommerdorf (July 13 - July 17)
Deaf Week - Randy Dignan (July 20 - 24)
15
Please select the camper's gender* This field is required.
Male
Female
16
Grade entering next school year
17
Insurance Provider & Policy #* This field is required.If you are self-pay, type "none"
Huge
Large
Normal
Small
Ok
Ok
18
Physician Name & Phone #
19
Date of Last Tetanus Shot (If none - please type "none")* This field is required.This is just for our camper medical records and not a pre-requisite for attending camp.
20
Immunizations up to date?* This field is required.This is just for our camper medical records and not a pre-requisite for attending camp.
YESNO
21
Has this camper been diagnosed with any of the following?* This field is required.The parent/guardian is responsible for providing an accurate medical history on the camper. If your child's medical diagnosis is not listed, please write it in the box below. All medical history MUST be documented on this form. I understand that all medications, including EpiPens, inhalers, or any other prescription or over-the-counter medication, must be in their original labeled containers and must be turned in to the designated camp medical staff upon arrival. Medications must be prescribed specifically to the camper who needs them and clearly labeled with their name. Campers are not permitted to share or use another person’s medication under any circumstance. If my child has been diagnosed with ADHD or a similar condition, I understand that a note may be required from a doctor, teacher, or another adult who can reasonably attest to the camper’s ability to function well in an organized, group setting for the duration of the camp week.
ADHD
Seasonal Allergies
Asthma
Epilepsy
Diabetes
Lactose Intolerance
None
Other
22
Please list all other medical history for camper in this box if not listed above.* This field is required.ALL medical history must be documented on this form. It is the parent/guardian's responsibility to provide complete and accurate medical information for their camper.
Huge
Large
Normal
Small
Ok
Ok
23
Please list all current medications, dosage, and schedule.* This field is required.All medications must be in their original packaging with the camper's name visible. If not in original packaging, it cannot be administered to the camper and the parent will be notified. Medications prescribed for someone other than the camper cannot be administered by the camp health officer unless a doctor's note comes with the prescription stating as such. Please ensure that all prescriptions and OTC medications are clearly labelled and cleared for camper use. The parent/guardian MUST list the following: Name of medication, dose, route (topical, oral, etc) and frequency (how often).
Huge
Large
Normal
Small
Ok
Ok
24
I give permission for Camp Liberty staff or volunteers to provide basic first aid and to administer the following over-the-counter medications as needed:* This field is required.Must be selected if you want your child to be able to receive this over the counter medication as needed.
Acetaminophen (Tylenol)
Ibuprofen (Advil/Motrin)
Diphenhydramine (Benadryl)
Antacid (Tums, etc.)
Dramamine (Motion Sickness)
Sunscreen
None of the above
Other
25
Please list all allergies (including dietary) and the severity.* This field is required.It is the parent/guardian's responsibility to provide the camp health officer an updated list of allergies/intolerances. If the camper experiences any further allergic responses after this form has been submitted, notify Camp Liberty immediately to provide an updated list of allergies.
Huge
Large
Normal
Small
Ok
Ok
26
Do You Have Another Camper to Register?
YESNO
27
Camper Name* This field is required.
First Name
Last Name
28
Upload a clear picture of the camper (no other individuals in photo):* This field is required.Camper's privacy will be protected and distribution of the image will not occur outside of camp liberty. This is for identification/safety purposes.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
29
Camper's Date of Birth
Date
Month
Day
Year
30
Age when attending camp:* This field is required.
31
Which Week of Camp is this camper registering for?* This field is required.
Junior Week 1 - Jethniel Wyler (June 22 - June 26)
Junior Week 2 - Davide Kim (July 6 - 10)
Teen Week 1 - Justyn Smith (June 29 - July 3)
Teen Week 2 - David Sommerdorf (July 13 - July 17)
Deaf Week - Randy Dignan (July 20 - 24)
32
Please select the camper's gender* This field is required.
Male
Female
33
Grade entering next school year
34
Insurance Provider & Policy #* This field is required.
Huge
Large
Normal
Small
Ok
Ok
35
Physician Name & Phone #
36
Date of Last Tetanus Shot (If none - please type "none")* This field is required.This is just for our camper medical records and not a pre-requisite for attending camp.
37
Immunizations up to date?* This field is required.This is just for our camper medical records and not a pre-requisite for attending camp.
YESNO
38
Has this camper been diagnosed with any of the following?* This field is required.The parent/guardian is responsible for providing an accurate medical history on the camper. If your child's medical diagnosis is not listed, please write it in the box below. All medical history MUST be documented on this form. I understand that all medications, including EpiPens, inhalers, or any other prescription or over-the-counter medication, must be in their original labeled containers and must be turned in to the designated camp medical staff upon arrival. Medications must be prescribed specifically to the camper who needs them and clearly labeled with their name. Campers are not permitted to share or use another person’s medication under any circumstance. If my child has been diagnosed with ADHD or a similar condition, I understand that a note may be required from a doctor, teacher, or another adult who can reasonably attest to the camper’s ability to function well in an organized, group setting for the duration of the camp week.
ADHD
Seasonal Allergies
Asthma
Epilepsy
Diabetes
Lactose Intolerance
None
Other
39
Please list all other medical history for camper in this box if not listed above.* This field is required.ALL medical history must be documented on this form. It is the parent/guardian's responsibility to provide complete and accurate medical information for their camper.
Huge
Large
Normal
Small
Ok
Ok
40
Please list all current medications, dosage, and schedule.* This field is required.All medications must be in their original packaging with the camper's name visible and
Huge
Large
Normal
Small
Ok
Ok
41
I give permission for Camp Liberty staff or volunteers to provide basic first aid and to administer the following over-the-counter medications as needed:* This field is required.Must be selected if you want your child to be able to receive this over the counter medication as needed.
Acetaminophen (Tylenol)
Ibuprofen (Advil/Motrin)
Diphenhydramine (Benadryl)
Antacid (Tums, etc.)
Dramamine (Motion Sickness)
Sunscreen
None of the above
Other
42
Please list all allergies (including dietary) and the severity.* This field is required.It is the parent/guardian's responsibility to provide the camp health officer an updated list of allergies/intolerances. If the camper experiences any further allergic responses after this form has been submitted, notify Camp Liberty immediately to provide an updated list of allergies.
Huge
Large
Normal
Small
Ok
Ok
43
Do You Have Another Camper to Register?
YESNO
44
Camper Name* This field is required.
First Name
Last Name
45
Upload a clear picture of the camper (no other individuals in photo):* This field is required.Camper's privacy will be protected and distribution of the image will not occur outside of camp liberty. This is for identification/safety purposes.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
46
Camper's Date of Birth* This field is required.
Date
Month
Day
Year
47
Age when attending camp:* This field is required.
48
Which Week of Camp is this camper registering for?* This field is required.
Junior Week 1 - Jethniel Wyler (June 22 - June 26)
Junior Week 2 - Davide Kim (July 6 - 10)
Teen Week 1 - Justyn Smith (June 29 - July 3)
Teen Week 2 - David Sommerdorf (July 13 - July 17)
Deaf Week - Randy Dignan (July 20 - 24)
49
Please select the camper's gender* This field is required.
Male
Female
50
Grade entering next school year
51
Insurance Provider & Policy #* This field is required.
Huge
Large
Normal
Small
Ok
Ok
52
Physician Name & Phone #* This field is required.
53
Date of Last Tetanus Shot (If none - please type "none")* This field is required.This is just for our camper medical records and not a pre-requisite for attending camp.
54
Immunizations up to date?* This field is required.This is just for our camper medical records and not a pre-requisite for attending camp.
YESNO
55
Has this camper been diagnosed with any of the following?* This field is required.The parent/guardian is responsible for providing an accurate medical history on the camper. If your child's medical diagnosis is not listed, please write it in the box below. All medical history MUST be documented on this form. I understand that all medications, including EpiPens, inhalers, or any other prescription or over-the-counter medication, must be in their original labeled containers and must be turned in to the designated camp medical staff upon arrival. Medications must be prescribed specifically to the camper who needs them and clearly labeled with their name. Campers are not permitted to share or use another person’s medication under any circumstance. If my child has been diagnosed with ADHD or a similar condition, I understand that a note may be required from a doctor, teacher, or another adult who can reasonably attest to the camper’s ability to function well in an organized, group setting for the duration of the camp week.
ADHD
Seasonal Allergies
Asthma
Epilepsy
Diabetes
Lactose Intolerance
None
Other
56
Please list all other medical history for camper in this box if not listed above.* This field is required.ALL medical history must be documented on this form. It is the parent/guardian's responsibility to provide complete and accurate medical information for their camper.
Huge
Large
Normal
Small
Ok
Ok
57
Please list all current medications, dosage, and schedule.* This field is required.All medications must be in their original packaging with the camper's name visible and
Huge
Large
Normal
Small
Ok
Ok
58
I give permission for Camp Liberty staff or volunteers to provide basic first aid and to administer the following over-the-counter medications as needed:* This field is required.Must be selected if you want your child to be able to receive this over the counter medication as needed.
Acetaminophen (Tylenol)
Ibuprofen (Advil/Motrin)
Diphenhydramine (Benadryl)
Antacid (Tums, etc.)
Dramamine (Motion Sickness)
Sunscreen
None of the above
Other
59
Please list all allergies (including dietary) and the severity.* This field is required.It is the parent/guardian's responsibility to provide the camp health officer an updated list of allergies/intolerances. If the camper experiences any further allergic responses after this form has been submitted, notify Camp Liberty immediately to provide an updated list of allergies.
Huge
Large
Normal
Small
Ok
Ok
60
Do You Have Another Camper to Register?
YESNO
61
Camper Name* This field is required.
First Name
Last Name
62
Upload a clear picture of the camper (no other individuals in photo):* This field is required.Camper's privacy will be protected and distribution of the image will not occur outside of camp liberty. This is for identification/safety purposes.
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
Cancelof
63
Camper's Date of Birth* This field is required.
Date
Month
Day
Year
64
Age when attending camp:* This field is required.
65
Which Week of Camp is this camper registering for?* This field is required.
Junior Week 1 - Jethniel Wyler (June 22 - June 26)
Junior Week 2 - Davide Kim (July 6 - 10)
Teen Week 1 - Justyn Smith (June 29 - July 3)
Teen Week 2 - David Sommerdorf (July 13 - July 17)
Deaf Week - Randy Dignan (July 20 - 24)
66
Please select the camper's gender* This field is required.
Male
Female
67
Grade entering next school year
68
Insurance Provider & Policy #* This field is required.
Huge
Large
Normal
Small
Ok
Ok
69
Physician Name & Phone #* This field is required.
70
Date of Last Tetanus Shot (If none - please type "none")* This field is required.This is just for our camper medical records and not a pre-requisite for attending camp.
71
Immunizations up to date?* This field is required.This is just for our camper medical records and not a pre-requisite for attending camp.
YESNO
72
Has this camper been diagnosed with any of the following?* This field is required.The parent/guardian is responsible for providing an accurate medical history on the camper. If your child's medical diagnosis is not listed, please write it in the box below. All medical history MUST be documented on this form. I understand that all medications, including EpiPens, inhalers, or any other prescription or over-the-counter medication, must be in their original labeled containers and must be turned in to the designated camp medical staff upon arrival. Medications must be prescribed specifically to the camper who needs them and clearly labeled with their name. Campers are not permitted to share or use another person’s medication under any circumstance. If my child has been diagnosed with ADHD or a similar condition, I understand that a note may be required from a doctor, teacher, or another adult who can reasonably attest to the camper’s ability to function well in an organized, group setting for the duration of the camp week.
ADHD
Seasonal Allergies
Asthma
Epilepsy
Diabetes
Lactose Intolerance
None
Other
73
Please list all other medical history for camper in this box if not listed above.* This field is required.ALL medical history must be documented on this form. It is the parent/guardian's responsibility to provide complete and accurate medical information for their camper.
Huge
Large
Normal
Small
Ok
Ok
74
Please list all current medications, dosage, and schedule.* This field is required.All medications must be in their original packaging with the camper's name visible and
Huge
Large
Normal
Small
Ok
Ok
75
I give permission for Camp Liberty staff or volunteers to provide basic first aid and to administer the following over-the-counter medications as needed:* This field is required.Must be selected if you want your child to be able to receive this over the counter medication as needed.
Acetaminophen (Tylenol)
Ibuprofen (Advil/Motrin)
Diphenhydramine (Benadryl)
Antacid (Tums, etc.)
Dramamine (Motion Sickness)
Sunscreen
None of the above
Other
76
Please list all allergies (including dietary) and the severity.* This field is required.It is the parent/guardian's responsibility to provide the camp health officer an updated list of allergies/intolerances. If the camper experiences any further allergic responses after this form has been submitted, notify Camp Liberty immediately to provide an updated list of allergies.
Huge
Large
Normal
Small
Ok
Ok
77
Camp Liberty Waiver, Medical Release, and Photo Release* This field is required.I, the undersigned parent or legal guardian of the camper named in this registration, hereby grant permission for my child to participate in all activities at Camp Liberty, located at 483 F County Road 275, Oakwood, TX 75855. I understand that these activities may include, but are not limited to, water games, hiking, field games, team competitions, archery, axe throwing, slingshots, and use of a .22 rifle range, under the supervision of qualified staff and volunteers. I understand that while every effort will be made to provide a safe and secure environment, participation in camp activities involves inherent risks, including the risk of injury, illness, or accident. I acknowledge and accept these risks and agree to hold Camp Liberty, its staff, volunteers, officers, directors, and property owners harmless from any liability, claim, or cause of action arising out of or related to any injury, illness, accident, or loss incurred by my child during camp. In the event of an emergency, I hereby authorize Camp Liberty staff or volunteers to act on my behalf to obtain emergency medical treatment for my child. I give permission for a licensed physician, emergency medical personnel, or other qualified healthcare provider to administer necessary medical treatment, including hospitalization, anesthesia, surgery, injections, medication, or diagnostic procedures. I understand that reasonable efforts will be made to contact me prior to the initiation of any such treatment, but if I cannot be reached, I consent to the necessary care for the safety and well-being of my child. I understand that I am responsible for all medical costs and expenses incurred as a result of such treatment, including but not limited to physician fees, hospital bills, medications, and ambulance services. I release Camp Liberty and its representatives from financial responsibility for any such care provided. I also authorize Camp Liberty staff to administer cardiopulmonary resuscitation and basic first aid as needed, administer all medications brought by the camper, and to provide any over-the-counter medications that I have approved on the medication section of this registration form. 📸 Photo and Media Release I give permission for photos and videos of my child to be taken during the course of camp and used in Camp Liberty's promotional materials, social media posts, ministry updates, and website. I understand that no identifying personal information will be used or disclosed without additional consent.
YESNO
78
I verify that I have read and understand all of the above information. I certify that I have completed this form accurately and to the best of my knowledge. I understand and agree to the waiver, medical release, and photo release as outlined above.
YESNO
79
Registration Payment* This field is required.Payment is due at time of registration. The remaining $225 cost of camp will be due upon arrival. (Card, Cash, or Check)
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ORDER SUMMARY
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Registration FeeRegistration is $25 per camper
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Camp FeeCamp is $225 Per Camper (please add additional based on how many campers you are registering)
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