RimRock

June 18 - 22, June 25 - 29, and August 6 - 10

Please check the session you wish your child to attend

June 18 - 22

June 25 - 29

August 6 - 10

I need acampership

I need a ride

I can help with transportation

Fee: $150 Return this form and $100 Deposit to: PO Box 398, Casper, Wyoming 82602

Campers Name A value is required M F

Campers Age A value is required.

Grade Entering A value is required.

Home Address A value is required.

City A value is required.

State A value is required.

Zip Code A value is required.

Parent or Guardian A value is required.

Work Phone A value is required.

Other Phone A value is required.

Family Physician A value is required.

Physician Phone A value is required.

Emergency Contact A value is required.

Phone A value is required.

Home Church A value is required.

Found out about camp from A value is require

Place my child in a group with A value is required.

Permission to use my child's picture for advertising and promotional materials Y N

CAMPER'S HEALTH HISTORY

Allergies to food and or Drugs A value is required.

Is Child taking any Medications (please list) A value is required.

Is Physician presently treating camper? Y N

If Yes Please explain

List conditions that would prevent child from participating in an activity A value is required.

Other Information

Parents or Guardian's Insurance A value is required.

Policy Number A value is required.

Adventures in Christian Kamping assumes no liability for loss or damage to camper's personal property. We further recognize the right to refuse admission of or expel from camp any camper whose influence is in any way detrimental or harmful to the best interest of others. We also realize that in the event of illness or injury while attending the above activities, medical treatment may be required We hereby give our permission for any such treatment to be rendered and we agree to bear the cost of such treatment. We, the undersigned, (Parent/Guardian) of above camper, do hereby fully and forever release, hold harmless and discharge Adventures in Christian Kamping and their employees and all persons whomsoever directly or indirectly liable, from any and all other claims or demands, actions, causes of action, damages, costs, loss services, of any of them, or their agents or representatives causing personal injuries, conscious suffering, death or property damage, arising out of, or related in any fashion to and all related activities associated with the activities. We are aware of all risks related to all activities and dangers associated therewith. The terms of this release and indemnification agreement are contractual and not a mere recital, and contain the entire agreement between the parties hereto. This agreement is also binding upon my heirs, devises, executors, administrators, assigns and successors in interest.

I DO HEREBY AFFIRM THAT I HAVE READ THE FOREGOING RELEASE AND INDEMNIFICATION, AND I REALIZE THAT I AM WAIVING POTENTIAL VALUABLE CAUSES OF ACTION, BUT AM DOING SO ON MY OWN FREE WILL AND VOLITION.

Signature A value is required.

Date A value is required.