Sign Up – C.O. Mollenhour Camp

Boys Week: July 11-16

Girls Week: July 18-23

If you are registering two campers, please register them here.

2021 Camp Registration

Donation Amount:

$ 225.00

Camper’s Name

Date of Birth

Age During Camp

Camp Week

Return Camper

Years Attended Camp

Shirt Size

Street Address

City

State

Zip Code

Parents/Guardians Names

Cell Phone

Work Phone

Emergency Contact

Relationship

Cell Phone

Work Phone

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

Will your camper be taking medication during camp week?

Please list any medications your camper will be taking during camp week.

Please list any other medical information here.

Personal Info

First Name *

Last Name

Email Address *

Credit Card Info

This is a secure SSL encrypted payment.

Donation Total: $225.00