Register Two Campers Boys camp is currently full. Please email us at [email protected] to be put on the waiting list. Donation Amount: $ 425.00 First camper’s Name * Required Date of birth * Required Age during camp * Required Camp Week – select – Girls Week Years attended camp Shirt Size * Required – select – Youth S Youth M Youth L Adult S Adult M Adult L Adult XL Street Address * Required City * Required State * Required Zip Code * Required Parents’/Guardians’ Names * Required Cell Phone * Required Work Phone * Required Emergency Contact * Required Relationship * Required Cell Phone * Required Work Phone * Required By choosing yes to this release form as marked below, I authorize C.O, Mollenhour Conservation Camp, to use the following personal information of my child: (1) My child’s picture – including photographic, motion picture, and electronic (video) images. (2) My child’s voice – including sound and video recordings. I hereby grant C.O. Mollenhour, its subsidiaries, licensees, successors, and assigns, the right to use, publish, and reproduce, for all other purposes, my child’s name, pictures of my child in film or electronic (video) form, sound and video recordings of my child’s voice, and printed and electronic copy of my voice, and printed and electronic copy of the information described in sections (1) and (2) above in any and all media, including, without limitation, cable and broadcast television and the internet, and for exhibition, distribution, promotion, advertising, sale, press conferences, meetings, hearings, educational conferences, and in brochures and other print media. This permission extends to all languages, media, formats, and markets known or herby devised. This permission shall continue forever unless I revoke the permission in writing. I further grant C.O. Mollenhour all right, title, and interest that I or my child may have in all finished pictures, negatives, reproductions, and copies of the original print, and further grant C.O. Mollenhour the right to give, sell, transfer, and exhibit the print in copies or facsimiles thereof, for marketing, communications, or advertising purposes, as it deems fit. I also waive any right to inspect or approve finished photographs, audio, video, multimedia, or advertising recordings and copy or printed matter or computer-generated scanned image and other electronic media that may be used in conjunction there with or to approve the eventual use that it might be applied. I acknowledge that I have read the foregoing and I fully understand the contents. Photo Permissions * Required – select – Yes Will your camper be taking medication during camp week? * Required – select – Yes No Second camper’s Name * Required Date of birth * Required Age during camp * Required Camp Week * Required – select – Girls Week Years attended camp Shirt Size * Required – select – Youth S Youth M Youth L Adult S Adult M Adult L Adult XL Street Address * Required City * Required State * Required Zip Code * Required Parents’/Guardians’ Names * Required Cell Phone * Required Work Phone * Required Emergency Contact * Required Relationship * Required Cell Phone * Required Work Phone * Required By choosing yes to this release form as marked below, I authorize C.O, Mollenhour Conservation Camp, to use the following personal information of my child: (1) My child’s picture – including photographic, motion picture, and electronic (video) images. (2) My child’s voice – including sound and video recordings. I hereby grant C.O. Mollenhour, its subsidiaries, licensees, successors, and assigns, the right to use, publish, and reproduce, for all other purposes, my child’s name, pictures of my child in film or electronic (video) form, sound and video recordings of my child’s voice, and printed and electronic copy of my voice, and printed and electronic copy of the information described in sections (1) and (2) above in any and all media, including, without limitation, cable and broadcast television and the internet, and for exhibition, distribution, promotion, advertising, sale, press conferences, meetings, hearings, educational conferences, and in brochures and other print media. This permission extends to all languages, media, formats, and markets known or herby devised. This permission shall continue forever unless I revoke the permission in writing. I further grant C.O. Mollenhour all right, title, and interest that I or my child may have in all finished pictures, negatives, reproductions, and copies of the original print, and further grant C.O. Mollenhour the right to give, sell, transfer, and exhibit the print in copies or facsimiles thereof, for marketing, communications, or advertising purposes, as it deems fit. I also waive any right to inspect or approve finished photographs, audio, video, multimedia, or advertising recordings and copy or printed matter or computer-generated scanned image and other electronic media that may be used in conjunction there with or to approve the eventual use that it might be applied. I acknowledge that I have read the foregoing and I fully understand the contents. Photo Permissions * Required – select – Yes Will your camper be taking medication during camp week? * Required – select – Yes No Select Payment Method Stripe – Credit Card Personal Info First Name * Last Name Email Address * Credit Card Info This is a secure SSL encrypted payment. Donation Total: $425.00 {amount} donation plus {fee_amount} to help cover fees.