NICHOLS CAMP/ARISE CHAPEL

Highway 150, Lincoln County, Kentucky

 Larry Nichols, Camp Director

Registration Form

Parent/Guardian Information

Father/Guardian___________Mother/Guardian___________Emergency Contact_______

Parents Address___________________________________________________________

Tele/Work________________Tele/Work________________Tele(home)_____________

Employer________________Employer__________________Tele (work)____________

Child’s Name__________________________M___F___ Birthday__________________

Please Read Carefully  -  Signatures Required

Does your child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilla, heart condition, history of respiratory illness or any otaher significant medical condition?___Yes___No.  If yes, please state condition:____________________

If you wish to have a doctor contacted:  Doctor’s Name_______________Phone_______

Emergency Authorization:

I, the undersigned, parent or legal guardian of the participant, a minor, hereby authorize the camp supervisors, to act as my agents, to consent to medical treatment, at the nearest medical facility or hospital.

Authorization Signature__________________________________

Waiver of Liability, Disclaimer and Permission

I, the parent of the above named individual, acknowledge that participation in athletic events necessarily involves risk of physical injury.  I further acknowledge that the programs of Nichols Camp/Arise Chapel located on Highway 150 in Lincoln County, Kentucky, are primarily administered by volunteers, rather than paid professionals.  I acknowledge that time at the Camp will be used to learn more about Christ, participate in Bible Study, Gospel Singing and Campfires, and I hereby release discharge and hold harmless Nichols Camp/Arise Chapel, it’s employees, owners, volunteers, and other representatives from any claims arising out of or relating to any injury, physical or otherwise, that may result to said individual while traveling to and from Camp Nichols/Arise Chapel and participating at the Nichols Camp/Arise Chapel sponsored events.

Signature of Parent or Guardian_____________________________Date___________