Day Camp 2025-Camper Application

Camper's First and Last Name

Grade Completed

Date of Birth

Parent's First and Last Name

Address

Phone

This address will receive a confirmation email

Emergency Contact information

1st Emergency Contact Name:

Relationship to Child:

Emergency Contact Phone Number:

2nd Emergency Contact Name:

Relationship to Child:

Emergency Contact Phone Number:

Food Allergies/Sensitivities:

Medical Conditions:

Cal Skate of Rohnert Park-Thursday, July 17th, 2025

On the last day of camp,Thursday, July 17th, we will be taking campers to Cal Skate of Rohnert Park. Campers will need to bring a sack lunch from home for this day.

Skating Rink admission will already be paid for campers, however if campers would like to buy from concession or play any extra games available they will need to bring cash to cover cost. Campers are allowed to bring their own skates.

Parents/guardians who decide to join will need to cover their own admission/skate/concession fees.

Day camp hours this day will be the same as normal. Buses will leave Legacy Church campus at 11am and back around 4pm.

Please mark below if you would like your camper to ride the bus for the field trip or if you will be driving your own child to location.

Location Info:
Cal Skate of Rohnert Park
6100 Commerce Blvd
Rohnert Park, CA 94928

Cal Skate Trip-July 17th 11am-4:00pm

My child will be riding the bus for the field trip. I, the parent/guardian, will be transporting my own child for the field trip..

Medical/Liability Agreement

I hereby authorize Legacy Church and/or it’s representatives, as an agent for myself to procure medical, hospital or dental care for my child named on this form, in the event of injury or illness while the child is in the care of the above named. I understand that I am financially responsible for any care procured. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required. But given to provide authority on the part of my agent to consent to such medical care, should it become necessary.

I also authorize designated medical professionals to dispense over-the-counter medications as needed to the camper listed above.

I agree to not hold Legacy Church and/or any pastor/leader/ or any Legacy Church affiliate under any circumstance to be held responsible for any accidents or incidents while my child is partaking in Legacy Church Day Camp.

I agree for my child to abide by the rules and regulations of the camp, and to waiver any and all claims against Legacy Church, The Pentecostal Church of God, any of it’s District Board or it’s representatives, because of any injury or other damage that may be incurred to my child or their property in connection with, or incident to, Legacy Church and/or the Pentecostal Church of God.

Medical/Liability Agreement

Yes, I understand and agree to Medical/Liability statement.

Media Release

I hereby irrevocably consent to and authorize the unrestricted use and reproduction by Legacy Church or anyone authorized by Legacy Church, of any and all photographs and/or video images which Legacy Church have taken of the camper listed above, for use within the scope of Legacy Church, Legacy Kids, Legacy Youth, and or Pentecostal Church of God.

Media Release

Yes, I understand and consent to the media release. No, I don't consent to the media release.

E-Signature

E-Signature Date

Day Camp 2025-Camper Application

Description

Please Fix the Following