Event Registration

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Middle School Camp 2019 on Monday, July 8, 2019 @ 6:00 AM

**STOP** If you have not logged in using your Compassion Christian Church account please do so before completing this form. Create an account using the portal if you do not already have one before proceeding. Should you register without having logged in, you will not be able to view your student's registration at a later date to make final payments.
*Date of Birth:
*Gender:
*Age:
*Grade in School (for Fall 2019):
*Which campus does the student attend?:
*School the Student Currently Attends:
*Has the student been baptized? If so approximately when?:
Rooming Request (Please note that rooming requests are not guaranteed, but we do our best to accommodate requests.):
Name of Parent(s)/Legal Guardian:
Home Address (if different than participants):
*Parent/Guardian Phone Number:
*Parent/Guardian Email Address:
*Health Insurance:
Health Insurance Company:
Policy Number:
Primary Insured:
Family Physician:
Family Physician Office Phone Number:
Medications to be collected at check-in:
Has your student been diagnosed with any mental impairment or disorder?:
Is there any medical diagnosis that the staff/nurse needs to be aware of?:
Are there any medical devices that your student is on that the staff/nurse needs to be trained on?:
Are there any special dietary needs of your student? If so, will your student be bringing their own food for the week?:
Are there any allergies: food, medication, or environmental that the staff/nurse needs to know?:
I, the undersigned, certify that I am the parent or legal guardian of the above mentioned Participant. I hereby authorize my minor child named above to attend and participate in the Church Sponsored Activities (CSA) of the Children’s / Student Ministries of Compassion Christian Church, including any off-campus CSA for which I have registered him/her, during the period of one (1) year from the date of signing. I understand that my minor child must obey all established rules and follow the instructions of the person in charge of the CSA. I consent to and understand that the person in charge of the CSA or agents have the right to dismiss my child who is in their opinion a hazard to the safety and well-being of others, I understand that if my child is sent home under such circumstances I will be responsible for all associated costs incurred, including the cost of special travel arrangements. Prior to the participation of my minor child, I acknowledge that there are certain risks associated with certain Church Sponsored Activities, including, by way of example, physical injury due to activity-related accidents, and physical injury due to transportation-related accidents, illness or even death. Furthermore, In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. Accordingly, I acknowledge that participation in such activities involves certain dangers and risks which may expose my child to hazards of bodily injury or property damage, and which may result in my child being unable to contact me or be unable to receive immediate medical care and assistance if injury occurs. By signing this parental consent and liability form, I expressly warrant that my child named above is capable of withstanding both the physical and mental demands associated with any CSA for which s/he is registered. I also expressly assume all risks to my child’s participation in these CSA, whether such risks are known or unknown to me at this time. In recognition of these risks and realities, and in consideration of my child being offered the opportunity to participate in and benefit from Church Sponsored Activities, I agree on behalf of myself and my child to release, waive, and disclaim any and all liabilities of or claims against, CCC, its officers, board members, elders, agents, Pastors, employees, and all private persons or organizations Volunteering services without charge to transport, supervise, or chaperone my child while participating in such Church Sponsored Activities including, but not limited to any or all liabilities or claims for personal injury, property damage, court costs, attorneys’ fees and interest, however, caused or accrued, as a result of my child participating in the church-sponsored event. :
I hereby give Compassion Christian Church and their legal representatives and assigns, the right and permission to photograph, digitally record, videotape, or audio tape, my above named child while s/he is attending the Church or participating in any Church Sponsored Events occurring on or off an CCC church campus. I further agree that any or all of the material recorded may be used, in any form, in publications, including electronic publications, or in audio-visual presentations, promotional literature, advertising, or in other similar ways, and that such use shall be without payment of fees, royalties, special credit, or other compensation. I understand that all such recordings, in whatever medium, shall remain the property of CCC. :
I recognize that there may be occasions where the minor child named above, may be in need of first aid or emergency medical or dental treatment as a result of an accident, illness, or other health condition or injury. Therefore, I authorize any Pastor, CCC Staff Member, or Adult Volunteer ministry worker, in whose care the minor child has been entrusted, to consent to any X-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the provisions of the Medical Practice Act by the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. In so doing, I agree to pay all fees and costs arising from this action to obtain medical treatment. As parent or legal guardian of my minor child (Participant named above), I am responsible for the health care decisions of my minor child and am authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for dental, medical, and/or hospital care or treatment to be rendered to my minor child is legally sufficient and that no consent from any other person is required. By signing below I authorize any Pastor or Adult Volunteer, in whose care the minor child has been entrusted to authorize any hospital or physician or other health care provider to bill the following insurance company or companies for the payment of any services rendered to the minor child. I agree to assume responsibility for the charges for such care as rendered to the above named minor child. I authorize any hospital, physician, or other health care provider to release information from the minor child's medical record to the insurance company named above, in connection with the completion of any insurance claim form. :
I have read, understood and agreed to the information above. All releases, authorizations and permission granted above shall remain in effect for one year following the date of signature, unless revoked sooner in writing by the undersigned to Compassion Christian Church, 55 Al Henderson Blvd., Savannah, GA 31419. :
*Electronic Parent/Guardian Signature (Write your full name):
*Today's Date: