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Day Camp Application 2025

Child's Name

Parent/Guardian's Name and Number

Parent/Guardian's Authorization and Release for Child Participation

I have chosen to allow my child for whom I am their legal guardian, to attend Urban Impact Ministries Day Camp, in part, because of the activities and opportunities they offer my child.

I understand and acknowledge the activities which my child will be participating in, both on and off campus- including but not limited to waterslides, field trips, space walks, etc., entails both known and unanticipated risk of harm which could possibly result in injury to my child. Potential injury could be physical or emotional injury, degrees of paralysis, damage to property, etc.  I also acknowledge that such risk cannot be eliminated, in total, as well as, are influenced by factors beyond the control of Urban Impact Ministries, such as weather, equipment manufacturer’s malfunctions, and participants physical fitness and abilities, etc.

 

I hereby release and discharge, indemnify and hold harmless Urban Impact Ministries, its partners, its officers, directors, employees, agents, volunteers and assigns from all liability, claims, demands, cost, and expenses, and causes of action whatsoever arising out of, or in any way connected with any property loss and / or bodily injury including death and / or disability arising from my child’s participation in Urban Impact Ministries activities.

I hereby authorize Urban Impact Ministries’ staff to secure medical treatment for my child if necessary. 

I am aware that pictures/videos may be taken of my child participating in ministry activities, and I further authorize Urban Impact Ministries to use these for promotional purposes.

If you agree to the above please sign your signature below:
Signature

Address

Child's Date of Birth / Age / Grade (2025-26)

Child's School Name

Child's Allergies/Physical or Mental Limitations

How will you child get to and from camp?

Emergency Contact 1

Can this person pick up your child from camp?

Emergency Contact 2

Can this person pick up your child from camp?

Emergency Contact 3

Can this person pick up your child from camp?