Youth Cowboy Camp Registration

JC3 Youth Cowboy Camp

Online Registration Form

June 20-24, 2016
5:00 pm – 8:30 pm
     Jasper County Cowboy Church
       2200 W. Gibson St.  
Jasper, Texas 75951
409-384-5335 Office open 9 a.m. – 1 p.m. Monday – Friday


Youth's T-Shirt Size:
Youth's Name: *
Parent/Guardian Name: *
Address: *
Home Phone:
Parent's Cell Phone:
Youth's Cell Phone:
Parent's E-mail: *
Youth's Birthday: *
Grade Going into *
Medical, Allergies, or Special Needs:
Emergency Contact Name: *
Emergency Contact Phone: *
Emergency Contact Relationship: *
Youth will be driving self? *
Youth allowed to ride to and from Youth Cowboy Camp with the following
Authorized Pick-up #1 *
Authorized Pick-up #2
Do you attend Jasper County Cowboy Church? *
Guest of:
Do you attend church? *
If yes, where do you attend?
How did you hear about Cowboy Camp Bible School?


1. Release of Liability. I, for myself, my minor child and for the child's other parent and/or guardian, hereby release, waive, discharge, and covenant not to sue Jasper County Cowboy Church, and its officers, directors, employees, agents, volunteers, heirs and assigns of and from all liability, loss, claims, demands, possible causes of action, court costs, attorneys' fees and other expenses arising from any lawsuit that may otherwise accrue from any loss, damage or injury to my child's person or property in any way resulting from or connected with my child's attendance at JC3 Cowboy Camp Bible School, including, without limitation, the failure of anyone to enforce rules and regulations, failure to make inspections, or the negligence of other persons.

2. Photo Release. I give permission for my child's photo, which may be taken during the week, to appear in JC3 Newsletter and/or promotional publications. I give permission for my child's photo and/or video, which may be taken during the week, to appear on the church website.

3. Consent to Medical Treatment. In the event my child becomes ill or injured, I give my permission for a representative of Jasper County Cowboy Church to take whatever steps are reasonably necessary to render emergency first aid to my child. I also consent to such emergency medical treatment as may be reasonably necessary to insure the health and welfare of my child including, but not limited to, x-rays, anesthetic, medical or surgical diagnosis and treatment, hospital care and administration of drugs or medicine under the care of a licensed physician and/or surgeon.

Youth's Name *
Parent/Legal Guardian's Signature(Type your Signature) This will serve as your digital signature *

4. Consent to Ride Horse. I give permission for my child to ride a horse during the week. I release JC3 and the owner, trainer or any person handling the animal from all liability as stated in 1. Above. 

Please check one of the following: *
Name of Youth *
Parent/Legal Guardian's SignatureThis will serve as your digital signature *

FOR QUESTIONS CONTACT: Teron 409-594-6017 or Church Office 409-384-5335  

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