STUDENT INFORMATION

STUDENTS FULL LEGAL NAME

STUDENTS PREFERRED NAME

STUDENTS PHONE NUMBER

STUDENTS EMAL

STUDENTS BIRTHDAY

Month

Day

Year

WHAT GRADE WILL YOUR STUDENT BE IN FOR THE 25’- 26’ SCHOOL YEAR?

STUDENTS ADDRESS

PARENTAL INFORMATION

LEGAL GUARDIAN #1 FULL NAME

LEAGAL GUARDIAN #1 RELATION TO STUDENT

LEGAL GUARDIAN #1 PHONE NUMBER

LEGAL GUARDIAN #1 EMAIL ADDRESS

LEGAL GUARDIAN #2 FULL NAME

LEAGAL GUARDIAN #2 RELATION TO STUDENT

LEGAL GUARDIAN #2 PHONE NUMBER

LEGAL GUARDIAN #2 EMAIL ADDRESS

EMERGENCY CONTACT FULL NAME

EMERGENCY CONTACT RELATION TO STUDENT

EMERGENCY CONTACT PHONE NUMBER

EMERGENCY CONTACT EMAIL ADDRESS

STUDENT HEALTH INFORMATION

DOES YOUR STUDENT HAVE ANY HEALTH COMPLICATIONS

YES

NO

IF APPLICABLE, PLEASE EXPLAIN YOUR STUDENTS HELATH COMPLICATION

DOES YOUR STUDENT TAKE ANY MEDICATION THAT HE/SHE WILL NEED AT ANY POINT DURING REVIVE YOUTH CAMP

YES

NO

IF APPLICABLE, PLEASE LIST EVERY MEDICATION THAT WILL BE BROUGHT WITH AND TAKEN BY YOUR STUDENT AT REVIVE YOUTH CAMP. PLEASE INCLUDE HOW OFTEN YOUR STUDENT WILL NEED TO TAKE THEM

DOES YOUR STUDENT HAVE ANY ALLERGIES

YES

NO

IF APPLICABLE, PLEASE LIST ALL ALLERGIES

GENERAL INFORMATION

DO YOU CURRENTLY ATTEND CHURCH

YES

NO

IF APPLICABLE, WHAT CHURCH DO YOU ATTEND

WILL YOUR STUDENT HAVE SIBLINGS ATTENDING REVIVE YOUTH CAMP

YES

NO

ARE YOU COMFORTABLE WITH YOUR STUDENT SWIMMING

YES

NO

PLEASE CHOOSE YOUR STUDENTS SWIMMING ABILITY

PLEASE CHOOSE YOUR STUDENTS T-SHIRT SIZE

REVIVE MINISTRIES, INC. ACCIDENT WAIVER AND RELEASE

OF LIABILITY FORM

I acknowledge that participation in Revive Youth Camp can carry potential risks including, but not limited to, bodily injury to the participant, and I agree to assume all of the risks and hazards associated with the participant’s participation in Revive Youth Camp.

In consideration of receiving permission to participate in Revive Youth Camp, I hereby to action for myself, my executors, administrators, heirs, next of kin, successors and assign as follows:

(A) I WAIVE, RELEASE, AND DISCHARGE Jeremy I. Duggins and/or Revive Ministries, Inc., and any and all agents and employees currency and former, and/or representatives (each a “Releasee”) from any and all liabilities, claims, penalties, suits, demands, judgments, costs, interest, and expenses

(Including, attorney’s fees and costs) (each a “Loss” and collectively “Losses”) including but not limited to, Losses from or connected to participant's death, disability, personal injury, loss damage or theft of participant’s property or actions which may occur to participant in connection with Revive Youth Camp including traveling to and from Revive Youth Camp arising from either the participant or Jeremy I. Duggins and/or Revive Ministries, Inc.’s negligence, or from participant’s recklessness or intentional acts;

(B) I AGREE TO INDEMNIFY and HOLD HARMLESS Jeremy I. Duggins and/or Revive Ministries, Inc. for, from, and against any and all losses arising or resulting from participation in or travel to and from Revive Youth Camp arising from either the participant or the Releasee’s negligence, and/or from participant’s recklessness or intentional acts;

(C) THIS WAIVER, RELEASE, AND DISCHARGE, AND INDEMNIFICATION SHALL NOT EXTEND TO the gross negligence or intentional acts of Releasee’s acting within the scope of their employment.

In the event of an injury to the participant requiring medical attention, I grant permission to the Releasee to attend to the participant. In the event of an injury that requires further medical attention or in an emergency, the Releasee will attempt to contact the names listed as “Legal Guardian/Emergency Contact.” If efforts to reach the “Legal Guardian/Emergency Contact” are unsuccessful, I grant permission to the Releasee to seek further medical treatment for the participant.

I agree to accept full responsibility for and to pay the cost of medical care, transportation, and any other incidental expenses arising from any such event.

I certify that I have read this contract and that I fully understand it’s content. I certify that I am the participant’s true parent or legal guardian and that i have the authority to sign this document, and that the information i have filled out is true and correct.

PLEASE CONTINUE TO PAYMENT ONCE THE FORM IS COMPLETED

To secure your spot, a non-refundable $100 deposit is required. The remaining tuition amount must be paid by June 22nd.

$100