Girlz On Purpose Banner

Registration Form


PARTICIPANT INFORMATION


10 digits only : 5552221234
10 digits only : 5552221234
10 digits only : 5552221234

(First Tee-shirt Free)Tee-shirt Size:

More Tee-Shirts will be available after you complete this form.


PARENT /GUARDIAN INFORMATION


10 digits only : 5552221234
10 digits only : 5552221234

COST:
Cost - $25.00 Non-refundable registration fee due with registration form for each girl attending.
Tour cost: $55 per girl Additional Shirt $10.00
Total Cost: $55 per girl attending (please contact us reguarding a scholarship if you have more than two (2) girls attending.)

EARLY BIRD DISCOUNT:
Sign up today and pay only $35. This discount will be no longer available after August 15th 2018. See payment options after you complete this form.

HEALTH INFORMATION:
The information you provide here will be held in the strictest confidence. It will be kept on file in our health binder or carried by the camp director.


10 digits only : 5552221234

Medical, Physical, or Emotional Conditions (including Disabilities):

If your child must take medication while at the tour, please note here. All medications must be in their original containers and ne appropriately labled. Please do not give your child medication to them to bring to the tour; medications must be received by Girlz On Purpose Committee member and / or with director.


INSURANCE INFORMATION


I / (We), the undersign parent (s) of

give permission for my child receive

emergency medical or surgical treatment and hospitalization if necessary. I understand that every attempt will be made to contact me, or the emergency contact name mentioned above, before taking this action. I hereby waive the realease the Girlz On Purpose Committee, Project Compassion, NFP its staff and employees, agents, management, and volunteers from and liability for any injury of illness incurred while participating in this tour. I acknowledge that all participation is done at my child's own risk, without liability of any kind on the part of Project Compassion, NFP and/or it's collaborate partners. I understand that participation task may involve a risk of injury, and I hereby release, discharge, and hold harmless Project Compassion, NFP and/or Compassionate resource Center in connection with the same. By signing this form I acknowledge that Project Compassion, NFP and/or Compassionate resource Center are not responsible for damages or injuries which my be incurred or sustained during this program.

I have read this entire Informed Consent Agreement. I fully understand it and I agree to be legally bound by it.

Verify that your typed signature serve the same purpose as your hand signed signature.

Registration can be completed on-line by clicking submit and/or mail to Project Compassion, NFP 6609 West Main, Belleville or P.O. 6609 West Main St. Belleville IL 62223. FAILURE TO INCLUDE REGISTRATIONS FEE WILL DELAY YOUR CHILDS PARTICIPATION IN THE PROGRAM. Please make 618-397-1790 and/or email compassion@projectcompassionnfp.org