Base Sports Camp Registration

CAMP INFORMATION

2024 Theme: Courageous
August 5-9, 2024
Monday-Friday, 5:30pm-8:30pm
Silverton First Baptist Church
229 Westfield St. Silverton, OR

Sports Camp includes: Engaged coaching, positive role models, guided practice, and group huddles with Bible lessons, fun, music and games!

Early-Bird price through July 15: $50
Includes: Sports instruction, snacks, take home booklet, memory verse pin, and a bracelet.

Cost will increase to $65 on July 16.

For more info contact JD Winters at jd.w@silvertonfirstbaptist.org

CAMPER INFORMATION

CAMPER'S NAME

BIRTHDATE

GRADE (entering in the fall)

Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade

GENDER

Male Female

SPORT

Soccer (Co-ed) Basketball (Co-ed) Cheer (Girls)

CONTACT INFORMATION

PARENT(S) OR GUARDIAN'S NAME

ADDRESS

PHONE

ALT. PHONE

This address will receive a confirmation email

Do you regularly attend church? Where?

How did you hear about Sports Camp?

EMERGENCY INFORMATION

EMERGENCY CONTACT

PHONE

RELATIONSHIP

PHYSICIAN

PHYSICIAN PHONE

MEDICAL INFORMATION

List your child's recent injuries, chronic conditions, or anything they take medication for:

My child has the following allergies:

Drug allergies Food allergies Environmental Allergies None

Specify allergies here (or N/A):

Please list and explain any other relevant medical information that was not addressed above. Please include activities to be restricted.

PHOTOGRAPHY AND PUBLICITY RELEASE

If this box is marked then I DO NOT give permission for any of the sponsoring organizations to use photography that includes my child/ward. If this is blank, then I give permission to all sponsoring organizations to use my child's likeness, image, voice, and/or appearance as such amy be embodied in any media including but not limited to pictures, photos, video recordings, audio tapes, and digital images.

MEDICAL AND LIABILITY RELEASE

As legal guardian I realize no activity is without the possibility of unforseen hazards which could result in illness, injury, or worse. As a parent or guardian, I am aware of my responsibility to instruct my child/ward of the importance of conduct which will insure safety for all participants, and in doing so I assume full responsibility for my child/ward. I further agree to absolve and hold harmless the sponsoring oganizations and their representatives for damage, loss, death, injuries, and exposure to infectious/communicable disease to my child/ward.

By signing this form I give my child permission to participate in this activity, and give my permission to the leaders of this function to authorize any treatment necessary for any injury. I also certify that I a the legal guardian of this child and can sign fo rthem in a legal capacity.

Parent or Guardian please sign & date your agreement and understanding of the above statement:

PAYMENT INFORMATION

Payment $65

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

Base Sports Camp Registration

Description

Please Fix the Following