Name

One form per child

First Name

Last Name

Age and Grade in the Fall

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Name(s)

Phone Number

Church Home

Is your child baptized?

If no, would you like information about baptism?

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Allergies or Other Medical Conditions

**If your child has a food allergy, please provide an appropriate snack for your child.

How did you hear about the camp?

Medical Release

As a parent/guardian of the above player, I certify that he/she is in excellent health and has no physical, mental or emotional problems which are likely to prevent participation in strenuous physical play at soccer camp. I agree to hold harmless "Beyond the Basics" Soccer Bible Camp staff, Zion Lutheran Church and their agents and employees, and hereby release them from liability on account of injuries sustained by the player while participating in soccer camp activities. THE PARTICIPANT AND FAMILY ARE RESPONSIBLE FOR EACH PARTICIPANT'S OWN MEDICAL COVERAGE. There is potential risk in training and participating in any sport, and we have tried to create a safe environment. In the event of an emergency where medical treatment is required, I give permission for the soccer staff to obtain the service of a licensed physician and desired to be notified immediately. Your name in the box below indicates you agree with the medical release statement.

Photographic Release

I hereby give permission for Zion Lutheran Church, located at 4001 S. Pennsylvania Ave, Lansing, Michigan, the unrestricted right and permission to copyright and use, reuse, publish and republish pictures and/or likenesses of my child or those in which my child may be included, in whole or part, in any and all media for any lawful purpose, including the right to: --Record my child's participation and appearance on video tape, audio tape, film, photograph or any other medium (such as future promotional materials for Soccer Bible Camp, brochures, promotional videos, or posting of pictures on the church's website and social media). NAMES AND OTHER PERSONAL INFORMATION WILL NOT BE USED. I hereby waive any right that I may have to inspect or approve the finished product(s), as well as the advertising copy or other matter that may be used in conjunction therewith, or the use to which it may be applied. Your name in the box below indicates your permission. If you do not give permission, please type NO in the box.

Zion Evangelical Lutheran Church