MC Kids Camp: Blast Off!
Please fill out one form per child. This will help us to make sure that we have all of the supplies and t-shirts we need for each of your kiddos! (Note: We can only guarantee the correct-sized T-shirts for registrations that are completed on or before May 10th)

Dates: June 23-26, 2024
Time: 6-8pm each evening
Address: 1410 N Main St  Ellensburg, WA 98926
Contact us at (509) 933-7800 or brenna.modine@mercercreek.org
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Email *
Parent's Name *
Parent's Cell Number *
Home Address *
Child's Name (First & Last) *
Child's Birthday *
What grade will your child be in during the 2024-2025 school year? *
What is your child's T-shirt size? *
Emergency Contact (Name & Phone Number) *
Please list who will likely be picking up your child that week. (Make sure to include yourself if applicable) *
Insurance Co AND Policy #
 *
Allergies? Please list them below
Bringing or taking any medications? Please list any below
Any physical, emotional, mental or behavioral concerns or limitations that our staff should be aware of?
Please Explain
 *
Is tetanus shot up-to-date?
 *
Is there anything else that we need to know about your child?
 *
I give permission for my child to be photographed and for photos to be used to promote MC Kids and MC Kids events on social media, the MCC website and printed materials.
 *
Please read the following disclosure:

I understand that in the event medical intervention is needed, every attempt will be made to immediately contact the persons listed on this form.  In the event I cannot be reached in an emergency, during the activity dates listed above, I hereby give my permission to the physician or dentist selected by the activity leader to hospitalize, secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary.  I understand that my insurance coverage will be used as primary coverage in the event medical intervention is needed.  Coverage by Mercer Creek Church's accident policy will be used as a backup for what my family's insurance does not cover.  I understand all reasonable safety precautions will be taken at all times by Mercer Creek Church and it's agents during the events and activities.  I understand the possibility of unforeseen hazards and know the inherent possibility of risk.  I agree not to hold Mercer Creek Church, its leaders, employees and volunteer staff liable for damages, losses, diseases or injuries incurred by the student named in this form.

By filling in my first and last name in the box below, I acknowledge that I have read and agree to the above disclosure.
A copy of your responses will be emailed to the address you provided.
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