Complete the form below in order to register your child for Summer Camp.
Summer Camp will be August 9-10, 2016
8:30 am – 4:00 pm

Required fields are noted with an *

Summer Camp Registration

General Information:

Child's Name*:

Date of Birth*: (mm/dd/yyyy)

School Grade for 2015-2016 School Year*: Age*:

Form Completed By*:

Parent/Guardian Name*:


City*: State*: Zip Code*:

Phone 1*: Number Type*:

Phone 2: Number Type:

How did you hear about our camp?

Shirt Size (Child Sizes)*:

Health History:

Medical conditions we need to know:


Present Medications:

Emergency Contacts*:

Emergency Contact 1



Emergency Contact 2:



Dismissal Information:
Only the following individuals will be allowed to pick up this child, NO EXCEPTIONS.

Name*: Relation*:

Name : Relation :

By clicking accept below, I certify the information is true and I agree to the statement below:

Release of Liability
By signing this Consent/Release Form, I acknowledge that ministries, programs and activities conducted by the Missouri Annual Conference of the United Methodist Church, the Missouri United Methodist Camping and Retreat Ministries and their related and affiliated organizations (collectively, the 'Conference'), especially, but not limited to, the Ignite mobile camps, Infuse community/residential camps, Intrepid Wildfire Camps, Spark Mini Mobile Camps, and Impact mission camps (individually or collectively, the "Camp(s)"), involve a certain amount of risk to individuals participating. Activities may include strenuous or moderately strenuous physical activities including, but not limited to climbing, swimming, boating, physically active games, jumping and manual labor. With this information, I acknowledge and consent to my or my minor child's participation in the Camp(s) for which they have enrolled. I further acknowledge and consent to any organized travel by van or bus as part of the activities conducted during the Camp(s).

Acknowledging the activities involved, I hereby release and hold harmless the Conference, its agencies, related organizations, employees, directors, counselors, leadership, volunteers and members from any and all liability that may arise as a result of my or my child's participation in the Camps except in the case of gross negligence or intentional misconduct.

Medical Consent for Treatment

During the Camp(s) in which I or my child are participating, I hereby authorize the adult camp director(s) and/or adult counselors designated to lead that camp to consent to any necessary examination, anesthetic, medical diagnoses or hospital care for my minor child named below. I understand that I will be notified as soon as possible in the event of an emergency. I also understand that designated volunteer first responders who are may or may not be professionally trained doctors or nurses may offer First Aid in the event of an accident.

Consent for Use of Photographs and/or Video

I give permission for the Conference to use images, pictures and/or video of myself or my child/children taken during the Camps in which they are participating. Such uses will only include the use of such images, photos or videos in electronic or printed promotional materials, on the Conference's website, the Missouri Methodist publication or as a display or presentation during the Missouri Annual Conference Sessions or other meetings held by the Conference.

I agree