Child's First Name (required)
Child's Last Name (required)
Gender (required) FemaleMale
Last Grade Completed (required) ---K-4K-5123456

T-Shirt Size (required) ---Youth-XSYouth-SYouth-MYouth-LAdult-SAdult-MAdult-LAdult-XLAdult-2XL

PARENT/GUARDIAN

Parent/Guardian's First Name (required)
Parent/Guardian's Last Name (required)

Mailing Address (required)
City (required) ZIP (required)

Phone 1 Type (required) ---HomeCellWork Number (required)
Phone 2 Type ---HomeCellWork Number
Phone 3 Type ---HomeCellWork Number

Email (required)

Name(s) of those authorized to pickup your child other than yourself:

EMERGENCY INFORMATION

Emergency Contact 1 (required)
Phone Number

Emergency Contact 2 (required)
Phone Number

Please list any allergies, medical problems, or restrictions we may need to be informed of:

MEDIA DISCLAIMER

Pictures and video will be taken during this event and used for church promotion, possibly appearing on our website, social media accounts, etc. We do not reference your child by name or provide any specific information regarding your child. (response required)

Media Permission
YES, I grant permission to use photos/video of my childNO, I do not grant permission to take any photos/video of my child

TRANSPORTATION

My child will need transportation to/from Camp Fusion.

Transporation is available on a limited basis to area families. Please contact the church office (office@livingwordnc.net or call 828.428.2351) for details.