Southern Illinois FCA

FCA Power Camps Use this form ONLY for the Massac County Power Camp.



ArrowRegister for any of our other Power Camps here.

Register for the Massac County Camp, June 27 - 29, 2017 at Massac County High School.

Home Phone:
Parents Name/s:
Parents Work or Cellular Phone:
School camper will attend in Fall 2017:
Grade level this coming fall:
Sex: M F
Adult T-shirt size:
Sports Clinic Choices
Sports Clinic Choices
Doctor's Name:
Preferred Hospital:
Does the child have any medical problems or currently taking any medication? (Y or N)
  Y N
If yes, please list:

Functions and Activities
It is my understanding that participating in the programs and recreational and other activities is a privilege. Prior to allowing participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

Release of Liability
By signing this Permission/Waiver Form, I expressly warrant that my child is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of participating in the activities, whether such risks are known or unknown to me or my child at this time. I further release this organization and its leaders, employees, volunteers, and agents from any claim that my child or I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of my family or estate, heirs, representatives, or assigns may have against this organization or its leaders, employees, volunteers, or agents. I further agree to indemnify and hold harmless this organization and its leaders, employees, volunteers, or agents from any and all claims arising from my child's participation in its activities and programs, or as a result of injury or illness during such activities.

First Aid and Emergency Medical Treatment
I recognize that there may be occasions where my child may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of this organization to seek and secure any needed medical attention or treatment for my child including hospitalization, if in the agent’s opinion such need arises.

In doing so I agree to pay all fees and costs arising from this action to obtain medical treatment.

I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment.

Release to use Image and Likeness
On occasion, the Fellowship of Christian Athletes (FCA) or its representatives takes photographs or makes an audio or videotape recording of children and/or adults involved in activities. Such photographs or video records may be used by staff and participants to remember the activities and participants.

Local news organizations may hear of our activities or events, and our organization may invite or allow them to photograph or record our events for news reporting on special interest features. I consent to the use of any such audio or visual record of the child named above to be used, distributed, or displayed as agents of the organization see fit. This consent includes but is not limited to: photographs, videotape, and audio recordings. Furthermore, I give permission for the child to be interviewed by the news media, or for such photographs and other audio or visual records to be used by the news media. (continued on back side)

In addition, such photographs and audio/visual recordings may be used in publications or advertising materials to let others know about our activities. These images may also be used by FCA or its agents to produce ministry resources for staff training, Camp or campus ministry or other uses to promote the ministry of FCA. FCA may also make these materials available for sale to the public.

By entering my Full Name as an electronic signature, I represent that I have read the above Permission/Waiver Form and am fully familiar with the contents thereof. I hereby consent to the Permission/Waiver Form, including the Release of Liability above, and agree that this Permission/Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.

Full Name of Parent or Guardian submitting this form (this serves as your digital signature):

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2012 - Southern Illinois Fellowship of Christian Athletes
719 S. Giant City Road, Carbondale, IL 62901   (618)  559-2735