Outdoor Outreach Camp Registration Form

Email Address:

Camper's Information

First Name:

Last Name:

Gender:MaleFemale

Date of Birth:
Example 03/02/2008

Address:

City:

State: —Please choose an option—ILWI

Zip:

Child's Home Phone:

Grade (Completed as of May 2024): —Please choose an option—K1

School:
—Please choose an option—ClarkBrother DuttonMerrillHackettRiverviewGastonFruzenCunninghamConverseRiversideBlackhawkRobinsonToddRock County ChristianVolunteer (Min 20hrs)Other (Added to waitlist)
Other Schools will be added to waiting list for review.

T-shirt size: —Please choose an option—YS (10/12)YM (14/16)SMLXL

Is this your first year at camp? —Please choose an option—YesNo

Parent/Guardian - Medical Emergency Contact & Pick up Release Consent

Parent/Guardian #1

First Name:

Last Name:

Address:

City:

State: —Please choose an option—ILWI

Zip:

Work Phone:

Cell:

Employer:

Parent/Guardian #2

First Name:

Last Name:

Address:

City:

State: —Please choose an option—ILWI

Zip:

Work Phone:

Cell:

Employer:

Child Lives With

Additional Medical and Alternate Pick up Release

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

Medical Release Information

Please list any medical problems, including any requiring maintenance medication(i.e. Diabetic, Asthma, Seizures).

Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?
YesNo
If yes, explain

Is your child allergic to any type of food or medication?
YesNo
If yes, explain

Transportation Information

Please select the Pick-up & Dropping off Location
New Life ChurchHackett Elementary SchoolRiverview Elementary SchoolParent drop off / pick up

Parent/Guardian Consent

I understand that I will be notified in the case of a medical emergency involving my child. In the event
that I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical
services in the event my child is injured or becomes ill. I hereby give consent to Outdoor Outreach or
Representatives to secure emergency medical treatment through the nearest trauma center, hospital,
or care facility for my child. I understand I am responsible for the resulting medical bills.

I hereby give permission for my child to be photographed during the camp, to be used on the website
and also to publicize events.

I hereby give permission for my child to participate in physical walking trips, field trips, special
excursions to places of interest, bus trips, van trips, and other field trips and activities sponsored by
Outdoor Outreach. I also give consent for my child to participate in physical fitness activities
sponsored by Outdoor Outreach. I understand and acknowledge that my child will hear a Christian
message during camp. Outdoor Outreach is not affiliated with any school district.

Outdoor Outreach and it’s co-organizers are not responsible for lost or damaged personal property.

I do hereby agree to hold free from any and all liability Outdoor Outreach, Williams Tree Farm, LLC,
Rockton, IL, and it’s respective officers, volunteers, employees, sponsors and member and do herby
for myself, my heirs, executors, and administrators waive, release and forever discharge any all rights
and claims for damage which I may hereafter accrue arising out of or in connection with my child’s
participation in any of the activities of Outdoor Outreach.

Printed Name of Parent/Guardian:

Parent/Guardian Signature:

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