Youth Rally Chaperone Registration

Name

First Name

Last Name

Birth date

YYYY

Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone number

Email Address

Dietary Restrictions or Allergies

Please include the severity of the allergy

Home church

How many teens will be coming from your church?

Approximate # is fine

Will you be staying overnight with the teens?

We need a chaperone for every 5-6 teens attending

Are you available to use your vehicle to transport teens during the rally?

How many seats do you have in your vehicle?

If available to transport teens

Agreements

Criminal Background Check Authorization: I hereby authorize Pioneer Bible Camp to obtain and/or request information about my criminal history through a background check. The background check authorization will be sent to your email. Release Agreement: I understand that Camp Insurance is for minor injuries up to $3500 and that my personal insurance is the primary coverage. While every effort is made for safety, I recognize that there are risks connected with some activities, including but not limited to, gym activities, sledding, group games, etc. I therefore agree to assume, as an explicit condition of my participation, any and all risks. I agree to hold harmless Pioneer Bible Camp and Fellowship Bible Church and its associates from any and all liability, claims, demands and causes of action whatsoever which may arise due to my participation.

I agree to the above

Please sign here

Electronic Signatures. This agreement, agreements ancillary to this agreement, and related documents entered into in connection with this agreement are signed when a party’s signature is delivered by facsimile, e-mail, or other electronic medium. These signatures must be treated in all respects as having the same force and effect as original signatures.

Date Signed

YYYY