REGISTRATION

CAMPER FIRST NAME

CAMPER LAST NAME

PARENT/GUARDIAN NAME

PHONE

ADDRESS

AM SESSION

Soccer

Art

PM SESSION

Basketball

Lego

EMERGENCY CONTACT NAME

EMERGENCY CONTACT PHONE (If different from above)

"My child has food allergies."

LIST ANY FOOD ALLERGIES (If box checked above)

SHARE ANY HEALTH CONDITIONS/ALLERGIES XCAMPS NEEDS TO KNOW:

"I understand I am responsible for providing a sack lunch for my child during the event."

***By signing below and submitting this form, I agree to grant permission for the above named child to participate at XCamps 2026 conducted by the Refuge Baptist Church and hosted at Van Buren Elementary School; consent to allow photography and video of my child participating in this program for use of publishing on social media and advertisement of XCamps; and grant permission for any adult staff member of XCamps to seek and authorize emergency medical attention on behalf of the child in my absence, hereby releasing The Refuge Baptist Church from any liability associated therewith.

Signing my name will serve as my electronic signature, and I represent that I am the parent or legal guardian of the named child.***

Signature

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