Clone of 2025 Camp Registration Form

Insurance Card issued in the name of:*
Address of the person on the insurance card*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of birth of the person on the insurance card:*

MonthDayYear
Date
YesNo
If yes, give name and relationship of dependent (or type none).*
Name of insurance company:*
Address of insurance company*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number of insurance company*
Format: (000) 000-0000.
Policy Number:*
Yes, I understand
Please take a picture of this child's insurance card, front and back. It will be needed to be clear to read.

Cancelof

WAIVER & RELEASE

My child plans to attend the Deafquake in Pisgah, Alabama on the week of July 2-6, 2026. I fully understand that injury or illness could result from or during my child’s participation in this event. In case of an accident or illness, I give my permission for the camp to release medical information in order for my child to receive medical treatment as deemed appropriate, including x-rays and any medical tests or treatments as determined by the hospital. I will assume full responsibility for any medical bills, damage or death. Deafquake will not be held responsible for accidents, injuries, or loss of property. I also understand that after a visit to the hospital for injury or illness, the Deaf Camp Directors will determine if my child can return to camp or needs to go home. BY SIGNING THIS DOCUMENT, YOU ARE WAIVING CERTAIN LEGAL RIGHTS AND ASSUME FULL RESPONSIBILITY FOR YOUR CHILD AT THIS RETREAT FOR THESE DATES.
Signature*

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2026 Camp Registration Form