Camp JUDA Winter

Emergency Contact/Authorized Pick Up Information

Please share at least one emergency contact, in addition to parents. Please include name, relationships, address, and phone number.
Contact #1

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
This contact is also authorized to pick my child/children up.
Contact #2

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
This contact is also authorized to pick up my child from school.
Contact #3

First NameLast Name
Relationship
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
This contact is also authorized to pick up my child from school.
Signature of Parent or Guardian
Date:

Statement of Authorization
Emergency Medical Treatment - I hereby give my consent to call a doctor or emergency medical service and for that doctor or emergency service to provide emergency medical or surgical treatment to my child.
Photo Release - I hereby grant my permission for my child's photo to be taken and shared in camp newsletters and updates.

Other
Media Release - I hereby grant my permission for my child's photo to be taken and used in flyers, and/or for any other advertisement purposes.

Other
Signature
Date:

My Products

Winter Camp $300.00

Quantity
Item subtotal:$0.00

Enter coupon

Total $0.00

JUDA Winter Camp