CLC Summer Camp 2024
Timing: June 10th- July 26th, 2024 (8am - 3pm - M-F)
Address: 225 W. 5th Ave. - Gary, IN
Contact us: (219) 880-4851
Cost: $200  W Trips and T-shirt  + $50 for transportation (limited)
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Email *
Student Name  *
Student Date of Birth
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Last 4 of SSN#
School Attending
Grade entering in fall of 2024
T-shirts
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Student T-Shirt Size
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Are you interested in Transportation through the CLC ($50 - Limited Spots)
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Parent Name 
Contact #
Parent Email *
Address, City, State
Emergency Contact (Name & Number) *
Medical Issues we should know about?
Does your child have a IEP/504 Plan *
If yes, please explain.
Transportation Methode *
Adults authorized to pick up. (Please list everyone that is authorized to pick your child up) Anyone picking up your child MUST be list below.

(Name, Relationship, Cell#, Alt#, email)
Allergy/Dietary restrictions
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I understand that I will have to pay $$ before my student can attend.  *
Required

For each child enrolled:  

 

• I recognize that certain hazards and dangers are inherent in out of school time trips, activities, and outdoor programs. These risks include, but are not limited to, the activities of sports, walking, exercise, hiking, running, jumping, canoeing, swimming, fishing, bike riding, wildlife encounters and all other activities.  I acknowledge that although CITY LIFE CENTER has taken safety measures in an attempt to minimize the risk of injury to participants, CITY LIFE CENTER can neither insure nor guarantee that the participants, equipment, vehicles and/or activities will be free of hazards, accidents and/or injuries. I therefore agree that I will instruct my child in the importance of knowing and following all safety rules and directions of staff, for both my child’s safety and the safety of all participants.    

 

• I understand that my child will be participating in field trips that will enhance their experience. My child has permission to take the mode of transportation provided by CITY LIFE CENTER to and from field trip sites. Students will be under the supervision of CITY LIFE CENTER staff and volunteers at all times.  CITY LIFE CENTER Students and supervising staff will be in contact with the CITY LIFE CENTER office staff by mobile phones.  

 

• I agree to direct my child to cooperate and comply with all reasonable directions and instructions from adult leaders at City Kids, and to observe all established rules of conduct.  I understand that if my child fails to observe those rules, or otherwise becomes disruptive, I will be notified, and I agree to come to the site to take my child home.  I understand and agree that any financial obligations resulting from vandalism, stealing, or related activity by my child will be my responsibility.  

 

• In consideration of CITY LIFE CENTER permitting my child to attend and participate in the out of school time activities, I release, forever discharge, and promise not to sue CITY LIFE CENTER or any of its affiliated entities, employees, agents, and volunteers from all liability for any loss or damage, and any claim or demands therefore on account of serious or mortal injury to the body, injury to psyche, or injury to property of my child, whether caused by negligence or other conduct by CITY LIFE CENTER while the child is participating in out of school time, or on or about the premises of Bethel Church, City Life Center or any of its facilities or equipment.  

 

• I further agree to indemnify and hold harmless City Life Center and Bethel Church, from any loss, liability, damage, or cost it may incur due to the presence of my child on or about the premises of its facilities or equipment, or while participating in out of school time, whether caused by the negligence of CITY LIFE CENTER or otherwise. 

 

• PHOTO RELEASE:  I grant the irrevocable and unrestricted right to use, reproduce, and publish photograph(s)or video(s) of my child, including his/her image and likeness for City Life Center, Bethel Church, publications, presentations, advertising, or website(s), or any other purpose and in any manner and medium; to alter the same without restriction; and to copyright the same. I hereby release City Life Center from any and all claims, actions, and liability of whatever nature and relating to the use of said photograph(s) and/or video(s). If this is not acceptable to you, please notify the Executive Director in writing.  

 

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E-Sign: I understand and agree to all of the rules and regulations of the CLC
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