2022 Summer Camp Applicaiton

Start Date
Referred by
Child/Children's Information*
(Click + (plus sign) to add multiple children's information.)
Child's First Name Child's Last Name D.O.B: Age: Upcoming Grade:
Child One T-Shirt Size*
(The T-shirt cost is included in the registration fee; however, any size over and XL is an additional $5.00)
- Child X-Small
- Child Small
- Child Medium
- Child Large
- Adult Small
- Adult Medium
- Adult Large
- Adult XL
- Adult 2X
- Adult 3X
Child Two T-Shirt Size
(The T-shirt cost is included in the registration fee; however, any size over and XL is an additional $5.00)
- Child X-Small
- Child Small
- Child Medium
- Child Large
- Adult Small
- Adult Medium
- Adult Large
- Adult XL
- Adult 2X
- Adult 3X
Child Three T-Shirt Size
(The T-shirt cost is included in the registration fee; however, any size over and XL is an additional $5.00)
- Child X-Small
- Child Small
- Child Medium
- Child Large
- Adult Small
- Adult Medium
- Adult Large
- Adult XL
- Adult 2X
- Adult 3X
Parent/Guardian’s Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Cell Number
Work Number
Email Address
Emergency Contact*
Phone*
People Authorized to pick up your child/children other than the above person(s):
Name
Relationship
Phone Number
Name
Relationship
Phone Number
Name
Relationship
Phone Number
Please list any medical condition or disabilities
May your child be given any medication for headache or stomach ache?*
- Yes
- No
Specify*
- Tylenol
- Motrin
- Aspirin
- Pepto-Bismol
- Benadryl
- Other

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Field Trip Permission Form, Liability Waiver, Photo and Medical Release

Please download and print the Field Trip Permission Form, Liability Waiver, Photo, and Medical Release. This form must be notarized and submitted in person. Click here to download form.
Consent*
I have downloaded the Field Trip Permission Form, Liability Waiver, Photo and Medical Release Form.
Summer Camp Wavier Document
ABSOLUTE WAIVER, RELEASE, INDEMNITY AND COVENANT NOT TO SUE
(Minor Form to be signed by a parent or legal guardian having a child 18 years or younger)

The undersigned , as the parent and natural or legal guardian of a Minor Child(ren), desires to allow the Minor Child(ren) to participate in and attend the Greater 2 nd Mt. Olive Baptist Church Summer Camp Enrichment Program on property in Dougherty County, Georgia ("the Property") owned by Greater 2 nd Mt. Olive Missionary Baptist Church, subject to the terms, conditions and understandings set forth herein. The officers, directors, shareholders, members, agents and employees of Mt. Olive are collectively referred to as the "Indemnified Parties" and individually as an "Indemnified Party"

The undersigned recognizes that, among other activities, the Mt. Olive Camp curriculum involves instruction in performing arts, sports, arts and craft, motivational speakers, field trips, sex education, swimming and recreational activities that can involve certain risks and dangers, and the undersigned desires to indemnify and hold the Indemnified Parties harmless from any such risks and dangers which may result to the Minor Child(ren) on or around the Property while attending the Mt. Olive Camps.

NOW, THEREFORE, for and in consideration of the right of the Minor Child(ren) to attend the Mt. Olive Camps and to participate in the activities therewith, performing arts, sports, arts and craft, motivational speakers, (speaking on subjects such as sex, money, drugs, and violence), horseback and all terrain vehicle (ATV) riding, swimming, field trips, and recreational activities and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the undersigned, for himself, the Minor Child(ren), his family, his heirs, administrators, executors, successors, devisees and assigns hereby agrees to and does hereby RELEASE, WAIVE, DISCHARGE, COVENANT NOT TO SUE, INDEMNIFY AND HOLD HARMLESS each Indemnified Party from and against all claims, demands, payments, suits, actions, recoveries, attorneys’ fees and judgments of whatsoever nature, kind and description, brought, recovered or extracted against any Indemnified Party for, or on account of, any loss, damage or injury (including death resulting therefrom) or any claim for loss, damage, injury or death received or sustained or alleged to have been received or sustained by the Minor Child(ren) on or around the Property while attending Mt. Olive Camps.

I sign this instrument voluntarily, and with full knowledge and understanding of the rights I hereby waive and release. If any provision hereof is invalid or unenforceable, the other provisions shall remain in full force and effect, and the remaining provisions hereof shall be construed liberally in favor of each Indemnified Party in order to effectuate the provisions hereof. This agreement shall be governed by and interpreted in accordance with the laws of the State of Georgia.
WITNESS THE SIGNATURE OF THE UNDERSIGNED, this day*
Parent Signature*
Name of Minor Child(ren)*

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Summer Feeding Program
All meals are provided by Mt. Olive Community Outreach Center, Inc. as an approved Sponsor through USDA’s Summer Feeding Program. All meals served are creditable and have been approved by Bright From the Start Department of Early Care and Learning Nutrition Department. Any meal deviations must also be approved by Bright from the Start. 1% milk is a requirement for breakfast, lunch or supper on a daily basis; however, if your child does not drink 1% milk, Mt. Olive is not required by BftS to provide substitutes. In the event your child provides a doctor’s excuse for milk, Mt. Olive will make every effort to accommodate your child if the notice is submitted with the completed summer camp application.

NON-DISCRIMINATION STATEMENT: In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.

Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.

To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form , (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; fax: (202) 690-7442; or email: program.intake@usda.gov . This institution is an equal opportunity provider.
Consent*
I have read the Milk Substitute Notice, the Non-Discrimination Statement, and the Complaint Procedure.
Name
Date

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Payment Option Selection:*
- Pay In Person
- Pay In Full
- Pay in Full Early - Pay Before May 28th
- 1st Month Only (6/6 - 6/30) - In Person
- 1st Month Only (6/6 - 6/30) - Pay Now
- 2nd Month Only (7/5 - 7/29) - Pay Before June 28th - In Person
- 2nd Month Only (7/5 - 7/29) - Pay Before June 29th - Online
Please select the way you would like to pay for your child. Please remember that your registration is not complete until a payment has been made. There is a 3% convenience fee for all online payments.
Quantity*
Please enter a number from 1 to 6.
Total
$0.00
After clicking submit, you will be directed to PayPal to make a payment. Please make sure that you received confirmation that your payment has been submitted.
Name
This field is for validation purposes and should be left unchanged.

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Click Here to Download Wavier Documents to Sign and Return (Required)

Click Here to Download Policy Document to Sign and Return (Required)

2022 Summer Camp Application

Step 1 of 4

Child's First Name	Child's Last Name	D.O.B:	Age:	Upcoming Grade: