Breakaway Field Day Registration 2022

Breakaway Field Days Registration

Parent Contact Info
Parent/ Guardian #1 Name*
First Last
Parent/ Gardian #1 Email*
Parent/ Guardian #1 Phone*
Parent/ Guardian #1 Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Parent/ Guardian #2 Name
First Last
Parent/ Guardian #2 Email
Parent/ Guardian #2 Phone
Parent/ Guardian #2 Address (If Different)
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Emergency Contact
Name*
First Last
Relationship to Camper(s)*
Phone #1*
Phone #2
Number of Campers*
There is a $5 fee per camper. Please enter the number of campers you are registering. Once you click submit, you will be directed to Tithely to pay for your registration.
Camper #1
Name of First Camper*
First Last
Gender
Age of First Camper*
Please enter a number from 5 to 12.
Camp is for ages 5-12.
Any food allergies for first camper?
Any medical conditions that we should know about regarding first camper?
Camper #2
Name of Second Camper
First Last
Gender
Age of Second Camper
Please enter a number from 5 to 12.
Camp is for ages 5-12.
Any food allergies for second camper?
Any medical conditions that we should know about regarding second camper?
Camper #3
Name of Third Camper
First Last
Gender
Age of Third Camper
Please enter a number from 5 to 12.
Camp is for ages 5-12.
Any food allergies for third camper?
Any medical conditions that we should know about regarding third camper?
Camper #4
Name of Fourth Camper
First Last
Gender
Age of Fourth Camper
Please enter a number from 5 to 12.
Camp is for ages 5-12.
Any food allergies for fourth camper?
Any medical conditions that we should know about regarding fourth camper?
Camper #5
Name of Fifth Camper
First Last
Gender
Age of Fifth Camper
Please enter a number from 5 to 12.
Camp is for ages 5-12.
Any food allergies for fifth camper?
Any medical conditions that we should know about regarding the fifth camper?
CHILD PICK UP AUTHORIZATION
Name of Child(ren):*
AUTHORIZED PICK-UP PERSON:
Name | 1*
First Last
Relationship to Child | 1*
Phone | 1*
Name | 2
First Last
Relationship to Child | 2
Phone | 2
Name | 3
First Last
Relationship to Child | 3
Phone | 3
Please List T-Shirt Size for your camper(s)
- In my registration of my child/children for Breakaway Field Day, I hereby waive, release, and discharge any and all claims for damages for personal injury, property damages or which may hereafter occur to me as a result of participation in said event. This release is intended to discharge in advance Gashland EPC, its officials, officers, employees, volunteers and agents from liability, even though that liability may arise out of perceived negligence on the part of persons mentioned above. It is understood that some recreational activities involve an element of risk or danger of accidents, and knowing those risks, I hereby assume those risks. It is further understood and agreed that this waiver, release and assumption of risk is to be binding on my heirs and assignees.
- In addition, I hereby authorize Gashland Evangelical Presbyterian Church to publish photographs and videos taken of me and/or the undersigned minor children, and our names, for use in the Gashland Evangelical Presbyterian Church’s printed publications, website and training purposes. I release Gashland Evangelical Presbyterian Church from any expectation of confidentiality for the undersigned minor children and myself and attest that I am the parent or legal guardian of the children listed above and that I have the authority to authorize GEPC to use their photographs, videos, and names. I acknowledge that since participation in publications and websites produced by Gashland Evangelical Presbyterian Church is voluntary, neither the minor children nor I will receive financial compensation. I further agree that participation in any publication and website produced by Gashland Evangelical Presbyterian Church confers no rights of ownership whatsoever. I release Gashland Evangelical Presbyterian Church, its contractors and its employees from liability for any claims by me or any third party in connection with my participation or the participation of the undersigned minor children.
- I understand that:
  - The “Authorized Pick-Up Person” must be at least 18 years old and must provide a photo ID to the staff.
  - This authorization shall remain in force until edited or rescinded in writing by the signers of this authorization.
Consent*
I agree to the above policy.
Total
$0.00
Payment Instructions
Step 1: Click "Submit." Step 2: After you click "Submit," you will be directed to Tithely where you can pay the $5 per camper fee by credit/debit or directly from your bank account. Click on the dropdown menu on the right and select "Breakaway Field Days Registration." Fill in the rest of the information and click the "Give" button at the bottom. Your registration is not complete until payment is received!

Parent Contact Info

Emergency Contact

Camper #1

Camper #2

Camper #3

Camper #4

Camper #5

CHILD PICK UP AUTHORIZATION

Payment Instructions