Fillable Printable Retreat Registration Form - Howell's Mill | Christian Assembly
Fillable Printable Retreat Registration Form - Howell's Mill | Christian Assembly
Retreat Registration Form - Howell's Mill | Christian Assembly
HMCA Retreat Form
HMCA, 99 Christian Camp Road Ona, WV 25545
Office Phone:
304-743-4332 Website: www.howellsmill.org
Event Name:
Make checks payable to HMCA.
Camper Information:
Last Name: First Name:
Address:
City: State: ZIP:
Home Church:
Home Phone: 2
nd
#:
Email Address:
Birthday: Current Grade:
Please check one:Male [ ] Female [ ]
Emergency Contact:
Relationship to Camper:
Phone Number: Cell:
Allergies:_______________________________________
HMCA Retreat Form
HMCA, 99 Christian Camp Road Ona, WV 25545
Office Phone:
304-743-4332 Website: www.howellsmill.org
Event Name:
Make checks payable to HMCA.
Camper Information:
Last Name: First Name:
Address:
City: State: ZIP:
Home Church:
Home Phone: 2
nd
#:
Email Address:
Birthday: Current Grade:
Please check one:Male [ ] Female [ ]
Emergency Contact:
Relationship to Camper:
Phone Number: Cell:
Allergies:_______________________________________
Medical/Camp Liability Release
I understand that, in the event of an emergency,
HMCA will make every effort to contact those
people listed on this form. In the event that
HMCA in unable to contact myself or the
designated contact, I give my permission to the
physician selected by the camp management to
secure treatment for my child as named on this
form.
I understand that completion of this medical form
with mysignature grants my camper participation
in a HMCA program. I release HMCA staff,
faculty, officers, and management fromany
liability and shall not be held responsible for an
articles lost, stolen, or left at camp. HMCA has
my permission to use any video or photos taken of
my child while attending or participating in a camp
program.
Howell’s Mill Christian Assembly insurance
assists only medical injuries occurring during the
duration of the HMCA program. Individual
insurance coverage will be primarily responsible
for extended coverage and HMCA will be limited
secondary coverage only.
Parent/Guardian Signature
Date
Medical/Camp Liability Release
I understand that, in the event of an emergency,
HMCA will make every effort to contact those
people listed on this form. In the event that
HMCA in unable to contact myself or the
designated contact, I give mypermission to the
physician selected by the camp management to
secure treatment for my child as named on this
form.
I understand that completion of this medical form
with mysignature grants my camper participation
in a HMCA program. I release HMCA staff,
faculty, officers, and management fromany
liability and shall not be held responsible for an
articles lost, stolen, or left at camp. HMCA has
my permission to use any video or photos taken of
my child while attending or participating in a camp
program.
Howell’s Mill Christian Assembly insurance
assists only medical injuries occurring during the
duration of the HMCA program. Individual
insurance coverage will be primarily responsible
for extended coverage and HMCA will be limited
secondary coverage only.
Parent/Guardian Signature
Date
