Registration (Private) - Pine Acres Youth Camp

Camper Information

Camper Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Gender *

Male
Female

School Grade Entering Fall 2023 *

Birthdate *

Home Church

Medical Information

Health Insurance Carrier *

Subscriber Name *

Policy/Identification Number *

Special Medical Conditions / Medications Needed / Allergies

Emergency Contact Information

Contact Name *

First

Last

Relation to Camper *

Phone *

Pine Acres Youth Camp & Cascade Lake 4-H Camp Liability Release

I hereby approve this registration form, expressively waiving any and all claims against the sponsors of the camp, and Cascade Lake 4-H Camp, Inc., because of injury and/or damages that may be incurred to the applicant while at camp.

I also signify that I have read the camp information and guidelines. I understand the requirements for attending this camp and have reviewed them with my camper.

CLICK HERE to view the full Waiver of Liability & Indemnity Agreement

Acknowledgement of Liability Release *

By checking this box and signing below, I acknowledge that I have read and understand all of the terms of this Agreement and that I am voluntarily giving up substantial legal rights, including the right to sue Cascade Lake 4-H Camp, Inc.

Guardian Name *

First

Last

Guardian Signature *