Bound for Glory Camp Youth Group Permission Form Step 1 of 3 33% Youth InformationName of Youth(Required)Age(Required)School Grade(Required)1st2nd3rd4th5th6th7th8th9th10th11th12thSchool Name(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Any Known Allergies or Health Concerns?(Required) No Yes Known Allergies or Health Concerns(Required)Any Known Behavior Concerns?(Required) No Yes Known Behavior Concerns(Required) Guardian InformationGuardian Name(Required) First Last Phone(Required)Email(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency ContactsWe need two emergency contacts. If other than above, please listEmergency Contact 1 Name(Required) First Last Emergency Contact 1 Phone Number(Required)Emergency Contact 2 Name(Required) First Last Emergency Contact 2 Phone Number(Required)Allowed Pickup List(Required)NamePhone NumberRelationship Add RemoveClick the Plus Icon on the right to add any number of people. General Liability WaiverYouth's Name(Required) First Last General Liability Waiver Signature(Required)I, the parent/guardian, approve and give my permission for him/her to participate in any class or program offered by Bound for Glory Camp. By signing this waiver, I acknowledge that the activities carried on in the program carry certain risks for the participant. The parent/guardian has independently reviewed and evaluated the risks and determined to allow his/her child to engage in the program with full knowledge and acceptance of the risk. The registrant agrees to and hereby releases and forever discharges Bound for Glory Camp, their officers, employees, agents and volunteers from any and all liability for damages, loss or personal injury arising out of or related to camper’s participation in recreational programs. Photography Release(Required)I, the parent/guardian, give my permission for pictures or videos to be taken of my child and used for publicity/marketing purposes of Bound for Glory Camp. Over-the-counter productsI give permission to the staff of Bound for Glory camp to administer the following over-the-counter products according to the label instructions. Check all that you permit Advil/Tylenol Type Medication Bug Spray Sunscreen Antibiotic Cream Rash Cream Sunburn Lotion Antiseptic Spray Benadryl Over-the-counter products Permission Signature(Required)
