LUM Camp – Registration Form

BEFORE YOU BEGIN — Please review the application first and be sure that you have all of the information you need before filling out the form. You will NOT be able to save your work and return to this form at a later time. Please also read the LUM Camp Behavior Expectations and the HRCA Agreement.

When you have the information you need — fill out the registration form below.

When the registration form is completed and you’re ready — click SUBMIT.
IMPORTANT — Stay on this page until the form is done processing — otherwise, it may not go through. You will receive an email confirming that LUM has received your registration when it is submitted properly. When typing information into this form, please do NOT use only lower case or upper case letter.

LUM Camp – Important Information, click HERE
LUM Camp – main page, click HERE
Behavior Expectations for LUM Camp, click HERE
HRCA Agreement for Waiver and Release, Assumption of Risk & Indemnification, click HERE
For a PDF version of the LUM Camp Registration, click HERE


 

Fields marked with an * are required

CHILD'S INFORMATION -- the Camper


HOUSEHOLD INFORMATION - Camper's Family


Other Children in Your Household
Name & Date of Birth


EMERGENCY CONTACT INFORMATION
Someone other than Parent/Guardian

Emergency Contact #1
(NOT Parent/Guardian -- Someone other than Parent/Guardian)

Emergency Contact #2
(NOT Parent/Guardian -- Someone other than Parent/Guardian)


HEALTH INFORMATION - for CAMPER





SPECIAL INFORMATION

In order to help us plan for a great camp experience, please tell us about your child.



My child has my permission to attend LUM’s Summer Camp. I understand that it is LUM’s intention to make this camp a safe and enjoyable experience. However, in consideration for my child being permitted to take part in LUM’s Summer Camp, I, on behalf of my child, myself and any other person acting or claiming to act on behalf of my child, hereby release and discharge Lafayette Urban Ministry, Inc., its board members, staff, volunteers, employees, agents and insurers of and from any and all claims and liabilities for any injury or damages that my child may suffer resulting in any way from my child’s participation in LUM’s Summer Camp.


I have read and understand the Permission Statement; and I agree to the terms stated above.


Each child is expected to behave in a respectful way at camp. Listed below are rules each child will need to follow to make camp a wonderful experience for all:

1. No put downs or name calling. Camp is a time to have fun, show respect for each others and make new friends.
2. Each camper is expected to leave his hands and feet to himself and not get into others belongings. Therefore, we will not tolerate fist fights.
3. Be a good listener and follow directions.
4. Always stay with a counselor or adult leader. A camper is never to go off by him/herself.
5. Be a team player and display a good attitude.

As a parent/guardian of a camper, I have read and understand the rules of camp. I agree to bring my child home from camp if he/she is asked by the director to leave camp based on the child’s behavior.


I have read and understand the Behavior Expectations for Camp; and I agree to the terms stated above.


I authorize Lafayette Urban Ministry, Inc., and its staff, employees, and volunteers, to obtain and consent to any emergency medical care or treatment for my child which they believe necessary, and I request that Lafayette Urban Ministry, Inc., notify me as soon as practical in the event any such care or treatment is needed.  I also authorize the distribution of over-the-counter medications (such as Tylenol, cough syrup, etc.) by the LUM Summer Camp nurse or other health care provider except those medications which are listed above to which my child has an allergy.


I have read and understand the Authorization Statement; and I agree to the terms stated above.


Occasionally, Lafayette Urban Ministry uses pictures of children who participate in LUM programming for informational or publicity purposes. This can include reproducing pictures on our web site or in a newsletter or newspaper or for promotional pamphlets, or using quotes from participating children for any of the above purposes.

I give my permission for Lafayette Urban Ministry and its staff to use any pictures of or quotes from my child for informational and publicity purposes, including, but not limited to, reproduction in newspapers or newsletters, web sites, pamphlets or other promotional materials.


This/these permission(s) are valid for one calendar year from the date of this application.


I have read and understand the Media Consent Statement; and I agree to the terms stated above.


I give permission for Lafayette Urban Ministry to identify my child by name in captions of pictures of or quotes from my child for informational and publicity purposes, including, but not limited to, reproduction in newspapers or newsletters, web sites, pamphlets or other promotional materials.


This/these permission(s) are valid for one calendar year from the date of this application.


I have read and understand the Media Consent Statement; and I agree to the terms stated above.


It is my intention to waive any rights to sue or seek damages from HANGING ROCK CHRISTIAN ASSEMBLY, INC.; except where injury, death or disability results from HRCA gross negligence. I further agree to indemnify, hold harmless and defend HRCA against any and all claims for damages, costs, expenses or attorneys fees brought by any third party in connection with or arising out of my, or the above-listed participant’s involvement or participation. This Agreement shall be effective and binding upon my marital community, estate, heirs, agents, personal representatives and assigns. I accept responsibility of medical coverage while at Hanging Rock. Hanging Rock does not carry camper/guest/participant insurance. 


I hereby certify that I am over 18 years of age; I have carefully read the entire HRCA - Agreement for Waiver and Release, Assumption of Risks & Indemnification (link to entire document is above) and acknowledge that I understand and agree to all the terms and conditions. I have had the opportunity to ask any and all questions regarding this Agreement and the effect of the same. I assume all risks and waive and release certain substantial rights that I have or possess.


I am aware that "selecting YES" I am adding my electronic signature to this Agreement.




By submitting this form, you are adding your electronic signature to this application.