Registration Form

Household of Faith Church, Inc Camp H.O.M.E.
925 W Edgewood Ave
Jacksonville, Florida 32208

General Release of Liability:
In consideration of being allowed to participate in any way in Summer Camp and related events and activities the undersigned agrees to the following:

I acknowledge and fully understand that each participant will be engaging in activities that may involve risk or serious injury; including permanent disability and severe social and economic losses, which might result not only from their actions, inactions of negligence, but the action, inaction or negligence of others, the rules of play or the condition of the premises or of any equipment used. Further, that there may be risks not known to us or not reasonably foreseeable at this time. To the best of my knowledge, my daughter/son is physically fit to engage in the activity in question. I understand that Household of Faith Church Inc., The City of Jacksonville and the Kids Hope Alliance and their employees and agents will exercise reasonable care while my daughter/son is in their custody and care engaging in activities through the Summer Camp. I agree to hold Household of Faith Church Inc., The City of Jacksonville and the Kids Hope Alliance and its employees and agents harmless from any and all liability, which may arise while exercising their duty of care, relating to my daughter/son for personal injury or illness that may be suffered or any loss of property that may occur to my daughter/son while participating in the Summer Camp.

Administration of Medication & Medical Release Statement:
In case of accident or serious illness, and the agency/program is unable to reach me, I hereby authorize the agency/program to contact the physician indicated on the application and to follow his/her instructions: If it is impossible to contact this physician, the agency may make whatever arrangements necessary to provide care and treatment for my child.
In case of accident/serious illness where the immediate treatment of my child is not necessary, but he/she is unable to remain at the agency/program site, the agency/program will contact me or arrange transportation for my child. If the agency/program is unable to reach me, I authorize the agency/program to contact one of the persons indicated on the enrollment form and ask them to pick up and transport my child home.

Photo/Media Release:
I acknowledge and understand that the publicity activities such as interviews, photos, and videotaping may occur. I consent and permit my child, as a participant in Summer Camp and events, to be photographed, videotaped, and/or interviewed for publicity activities. _____YES

Parent/Guardian is responsible for transportation of youth to and from camp. CAMPERS WILL NOT BE ALLOWED TO WALK HOME WITHOUT AN AUTHORIZED INDIVIDUAL AGE 18 OR OLDER IF THE PARENT IS NOT AVAILABLE AND MUST SHOW IDENTIFICATION. Summer Camp youth participants must be picked up at the designated camp end time. Failure to comply may result in camper being removed from the camp.

_______________________ ________________________________ _______________
Child’s Name Parent or Guardian Signature Date
***PLEASE RETURN COMPLETED APPLICATION TO THE ADMIN OFFICE AT CHURCH***