Camp Eagle Teen Leadership Registration Form - July 16-20

Camper Name *
Camper Name
Parent/Guardian's Name *
Parent/Guardian's Name
Address *
Address
Preferred Phone Number *
Preferred Phone Number
Additional Phone Number
Additional Phone Number
Camper Date of Birth *
Camper Date of Birth
Emergency contact other than Parent/guardian *
Emergency contact other than Parent/guardian
Emergency Contact's Preferred Phone Number *
Emergency Contact's Preferred Phone Number
Additional Phone Number
Additional Phone Number
Name of Family Physician
Name of Family Physician
Family Physicians Phone Number
Family Physicians Phone Number
Please be specific
Date of Last Tetanus Shot
Date of Last Tetanus Shot
Parental Consent *
By clicking I AGREE below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. You consent to be legally bound by this Agreement's terms and conditions. You further agree that your use of a key pad, mouse or other device to select an item, button, icon or similar act/action, or in accessing or making any transaction regarding any agreement, acknowledgement, consent terms, disclosures or conditions constitutes your signature (hereafter referred to as "E - Signature"), acceptance and agreement as if actually signed by you in writing. You also agree that no certification authority or other third party verification is necessary to validate your E-Signature and that the lack of such certification or third party verification will not in any way affect the enforceability of your E -Signature or any resulting contract. You also represent that you are authorized to enter into this Agreement. Medical Authorization In case of medical emergency, I hereby give my permission to have the staff member in charge hospitalize my child and/or secure a licensed physician, surgeon, or anesthetist in providing the necessary care for my child as named on this registration form. I certify that my child is in good physical health and is able to participate in the entire camping program, except for the activities listed as restricted. I further give permission to the camp staff to administer Tylenol or Benadryl, if needed. I understand and agree that I will be responsible for any and all expenses associated with providing medical care for my child. Assumption of Risk & Indemnity Agreement I am aware that during certain events and activities on Camp Eagle property, there may be inherent risks associated with this as well as any other outdoor activity. These events include, but are not limited to, High and Low Ropes Courses, Swimming, Hiking, Challenge Courses, Team Building Exercises, games, paintball, The “Blob”, Hay Rides, archery, BB guns, tomahawk throwing, sling shots, Laser Tag, and all other camp related activities. Since Camper safety is of utmost importance to the Camp Eagle Staff, I agree that once made aware of the rules, regulations, and standards as set forth by Camp Eagle instructors, I will abide by them or accept dismissal without benefit of refund for refusing to follow such rules. In consideration of and as part payment for the right to participate in these events and activities, I have and do hereby assume all risks and will hold Camp Eagle and its sponsoring organization, Shenandoah Baptist Church, (along with all employees or agents of Camp Eagle and Shenandoah Baptist Church), harmless from any and all liability, actions, causes of action, debts, claims and demands of every kind and nature whatsoever which I now have or which may arise from or in connection with my and/or my child’s participation in outdoor program activities arranged for me and/or others by Camp Eagle. The terms hereof shall serve as a RELEASE AND ASSUMPTION OF RISKS and INDEMNITY for my heirs, executors, and administrators and for all members of my family. If participant is a minor, the undersigned parent or guardian gives permission for said minor to participate in events and activities sponsored by Camp Eagle and accept all risks as stated above. I hereby give permission for my child(ren) to be photographed or videotaped while participating in the events at Camp Eagle. I give Camp Eagle and their agents permission to use or distribute such photographs or video for any reasonable purpose including advertising or promotion. I understand this consent complies with Section 8.01-40 of the Code of Virginia or its equivalent. I have carefully read all the information from the Summer Guidelines and agree to cooperate and comply in all these areas. I understand that violations in any of these areas may result in the campers dismissal from Camp Eagle. By selecting OPTIONAL EXCURSIONS In addition to the aforementioned activities, I hereby give permission for my child to participate in the Optional Excursions selected during registration. I understand and assume all risks related to this activity. I understand some excursions are offered “off-site” and I give my child permission to ride the bus to and from that location. I also understand that Tubing the James and Horsemanship events require an additional Release Forms for Twin Rivers Outfitters & Blue Ridge Farms which needs to be signed before participation will be granted. I understand that my child will be supervised by Camp Eagle Staff while “off-site” and expect my child to follow all rules/guidelines given.
Parent's Electronic Signature *
Parent's Electronic Signature