LIBERTY CAMP
REGISTRATION 

Child's First Name*

Child's Last Name*

Email Address*

Child's Age/Grade (provide both) this Fall*

Parent Name*

Phone*

Phone Number During Camp Hours*

Address*

City/Village/Township and Zip*

Child's T-Shirt Size*XS(4-6)
S(6-8)
M(10-12)
L(14-16)
Adult S
Adult M
Adult L
Adult XL

Food/Health Allergies, etc.*

Check if child is a:*Boy Scout
Girl Scout/Brownie
Homeschooler
Other

Names of Sibling Campers*

How did you hear about Liberty Camp?*Friend/Neighbor/Relative
Phone Call
Email
Website
Facebook
Newspaper
Flyer
Radio
Other

Other: Please list

PHOTO AND VIDEO RELEASE FORM

I hereby authorize the Liberty Camp For Kids to take pictures and videos, reproduce, and/or publish all written and/or visual materials that are made during Liberty Camp For Kids' events, including photographs and video that may pertain to me or my children. This material may be used in publications, public affairs releases, social media, or recruitment materials. This authorization is continuous and may only be withdrawn by my specific rescission of this authorization. Liberty Camp For Kids may publish materials, use my name, my child's name, photograph, video, and/or make reference to me or my child in any manner that the Liberty Camp For Kids deems appropriate in order to promote/publicize the event.

Photo Auth*I ApproveI Disapprove

APPROVAL IS REQUIRED FOR ATTENDANCE AT CAMP. The undersigned hereby request and approve entrant's registration and participation in the Liberty Camp For Kids. In consideration of such registration, the undersigned hereby agree: that entrant's participation will be at the sole risk of entrant and the undersigned without liability to the Liberty Camp For Kids and their officers, members, and agents, all of whom the undersigned hereby agree to release, indemnify and hold harmless from any and all claims and expenses resulting from or relating to entrant's said participation.

Liability Auth*I approveI disapprove

Supply name of at least one person who has permission to pick up your child in an emergency. This may be revised at later date.

Name, Relationship to camper, contact number*

We are having a picnic beginning at 12:15 on Friday. Parents and siblings are invited. The main course will be provided along with lemonade. If you prefer another beverage, please feel free to bring one for you and your family. Parents attending are requested to bring an item from the list below that will serve 6-8. We will have the signup sheet displayed on Wednesday at the registration table if you are unsure at this time or wish to change your selection. Please bring a picnic blanket.

TO SHARE*A salad
A fruit
A snack
A dessert
None of the above

Please provide the number who will be attending, including the camper. Use zero if you will not be attending.

Number*

Please complete registration form and submit payment for each camper individually before beginning the registration process for additional campers.

Are you interested in being a volunteering?YesMaybeNot at this time

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