Full Name
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First Name
Last Name
Camp Name
Date of Birth
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Street Address, City, State, Zip
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Phone
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(###)
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####
Email Address
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Date(s) Requested
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Participant Information
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Please list individually those who will attend:
Name(s) DOB MM/DD/YYYY
Service Information
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1) Are you or any of your family members require a specific diet? (vegetarian, vegan, gluten free, etc)
2) Are there any food allergies we should be aware of?
3) Are there any health concerns you feel R.M. Pyles Boys Camp should be aware of? (Attach additional sheet if necessary)
Emergency Contacts - Please list at least 2 contacts
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Name:
Relationship:
Home Phone:
Cell Phone:
Liability Waiver
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In consideration of gaining membership or being allowed to participate in the activities and programs of R.M. Pyles Boys Camp and to use its facilities, equipment, and machinery in addition to the payment of any fee or charge, I do hereby waive, release and forever discharge R.M. Pyles Boys Camp and its officers, agents, employees, representatives, executors, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation in any activities or my use of equipment or machinery in the above mentioned facilities or arising out of my participation in any activities at said facility. I do also hereby release all of those mentioned and any others acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in any activities of R.M. Pyles Boys Camp or the use of any equipment at R.M. Pyles Boys Camp.
Image Release
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I/We grant R.M. Pyles Boys Camp, their agents and representatives the irrevocable, perpetual worldwide right to use mine/my family’s/my guests' names, voices and likenesses in any combination for purposes of promoting R.M. Pyles Boys Camp in all media, including but not by way of limitation, illustrations, advertising, publications, trade, and video programs. All film, photographs, negatives, tapes or recordings shall constitute the sole property of R.M. Pyles Boys Camp with full right of disposition in any legitimate manner whatsoever.
Background Check Agreement
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National Background Investigations, Inc.
Customized Background Screening Solutions…. Simplified
Acknowledgement and Authorization
I acknowledge receipt of the disclosure regarding background investigations and summary of your rights under the fair credit reporting act and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by R.M. Pyles Boys Camp at any time after receipt of this authorization and throughout my time up at camp. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or feral agency, institution, school or university (public or private), information services bureau, employer, or insurance to furnish any and all background information requested by National Background Investigation, Inc. PO Box 966 Stevensville, MD 21666 1800-798-0079 another outside organization acting on behalf of R.M. Pyles Boys Camp at any time after receipt of this authorization and throughout my time up at camp. I agree that Fax, electronic, or photographic copy of this Authorization shall be as valid as the original.
California applicants: by signing below, you also acknowledge receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION, INC PURSUANT TO CALIFORNIA LAW Please initial here if you would like to receive a copy of an investigation whenever you have the right to receive such copy under California Law.
I declare that all information presented herein is correct and complete, and conditions outlined by R.M. Pyles Boys Camp are accepted by me. My signature stands to that effect.
