Project 61 Registration and Release Form
This form is due ASAP. Contact Nate Boone at 9185578230 or nateboone@gmail.com with questions.
Camper may NOT attend
Project 61 without it.
Camper Information
Name: ___________________________________ Gender: ________
Age: _____ Grade: ________ Camper Cell #: _________________
Home Church: ____________________________________________
T:Shirt Size (circle one): S M L XL XXL
Student or Staff? (circle one)
Date of last tetanus booster (month/year): _________________
Bringing any medications to camp (circle one)? Y N
If yes, please specify medication and instructions
___________________________________________________________
___________________________________________________________
Any special medical issues, allergies, or other concerns?
___________________________________________________________
___________________________________________________________
Any special parental concerns or requests?
___________________________________________________________
___________________________________________________________
Emergency Contact Information
Name: ___________________________ Relationship: ___________
Home #: _____________________ Cell #: ______________________
Release Information
I am aware that during participation in activities at PROJECT 61,
certain risks and dangers may occur. These include, but may not
be limited to, the hazards of being in an urban area, the forces
of nature, and other reasons because of the content of some of
the ministries and activities. In consideration of these ministries
and activities, I do hereby assume all risks and will hold PROJECT
61 and its staff harmless from any and all liability, actions, cause
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 minor camper’s/staff’s or my participation in
any activities arranged for me by PROJECT 61. The terms hereof
shall serve as a RELEASE AND ASSUMPTION OF RISK for my heirs,
executors, and administrators and for all members of my family.
In case of accident or illness, PROJECT 61 will attempt to provide
first aid and arrange transportation to medical services if
needed. I give them permission to authorize medical services or
transportation as needed. Cost of medical care beyond first aid
is the financial responsibility of the ill or injured person. I
assume full responsibility for my minor camper’s/staff’s or my
health being such that the activities will in no way aggravate any
conditions present. I declare the statements on this form to be
true. I also agree that my minor camper/staff or I will follow the
camp rules at PROJECT 61 Camp; that I may be requested to take
my minor camper/staff home or to leave camp for violation of
camp rules; and I authorize PROJECT 61 Camp to seek necessary
emergency treatment for myself or my minor camper/staff.
Parent or Guardian signs for Students or Staff under 18; Staff
or Student signs if over 18
Signature: _________________________________________________
Date: _____________________________________________________