Jr Camp 24' Registration
Date: July 8-12  Cost: $80
Camp Address: Wood County 4H Camp 2203 Butchers Bend Rd, Mineral Wells, WV 26150
Contact Bro. Roger at 740.376.0440 or youth@twinriversbaptist.org
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First Name *
Last Name *
Gender *
Grade Going Into *
Birthday *
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Email *
Father's Name
Mother's Name
 Street Address *
City *
State *
Zipcode *
Parent's Cell Number *
Second Phone Number
T Shirt Size *
Church *
Cabin Mate Request (Only 1)
Medical Information
Insurance Company *
Doctor
Doctor's Phone Number
Medications Taken Regularly
Special Problems or Conditions 
Allergic Reactions
Activities to be Restricted
Arrival Information *
Departure Information *
Insurance Terms 

  In consideration of your accepting me or my child for participation in the camp program, I hereby, for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages that I may have against  Twin Rivers Baptist Church and its agents, employees, representatives, successors, and assigns for any and all injuries or damages suffered by myself or my child that arise out of the camp program sponsored by Twin Rivers Baptist Church. 

  I warrant that I have the right to authorize the foregoing and do hereby agree to hold Twin Rivers Baptist Church harmless of and from any and all such liability of whatever nature which may arise out of or result from such participation.

  For the consideration stated above, I further agree that in the event that my child or I should make any claim against Twin Rivers Baptist Church for damages arising out of the camp program, I will personally indemnify, defend, and hold harmless the organization and its agents, employees, representatives, successors, and assigns against any and all loss and damage occasioned thereby, including attorney’s fees.

  I have read and understand this Agreement and have willingly placed my signature below as evidence of my acceptance of all the conditions contained herein.

  In the event I cannot be reached in an emergency in a reasonable amount of time, I hereby give permission to the physician selected by Twin Rivers Baptist Church to hospitalize, secure proper treatment for, and to order injections, anesthesia, or surgery for my child.  

I also fully understand that, concerning insurance coverage, my insurance shall be primary and Twin Rivers Baptist Church’s shall be secondary.  For insurance purposes, this means that all claims must be submitted to the parents’/guardians’ insurance carrier first, then the unpaid balance will be paid by the church’s carrier.

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