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2021-2022

All-Star Starts Monday Oct. 18 or Tuesday Oct. 19 at the
Rock's Education Center, 309 W. Hensley Bvld.

PERMISSION AGREEMENT AND RELEASE OF LIABILITY:

IN CONSIDERATION of being allowed to participate, for which we hereby apply, in On The Rock Ministries, Inc., and related activities including receiving free transportation to said activities, we, the participant and his/her undersigned parent/guardian (if participant is not 18 or older), hereby acknowledge that we, with full knowledge and understanding of the risks involved, have voluntarily applied for the participant to participate in Rock related activities/events being conducted by On The Rock Ministries, Inc., from school to “The Rock” and to other locations for related activities; and the undersigned parent further grants his/her permission for the undersigned participant to participate in said program and related activities;  AND, we further do hereby for ourselves, our heirs, personal representatives, successors and assigns, HEREBY RELEASE, FOREVER DISCHARGE AND HOLD HARMLESS On The Rock Ministries, Inc. its successors, assigns, employees, directors, officers, agents, and volunteers and their heirs, successors, and assigns (both individually and in their corporate capacity) from any and all manner of claims, demands, damages, causes of action, suits, judgments and costs including attorney’s fees, by reason of any matter or thing whatsoever, and particularly growing out of or in anywise connected with, directly or indirectly, the aforesaid child’s participation in On The Rock Ministries, Inc. related activities including receiving free transpiration to said activities.

I Agree
to PERMISSION AGREEMENT AND RELEASE OF LIABILITY

 

ASSUMPTION OF THE RISK AND WAIVER OF THE LIABILITY RELATED TO CORONAVIRUS/COVID-19:

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited the congregation of groups of people. The Rock has put in place preventative measures to reduce the spread of COVID-19; however, the Rock cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the Rock could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the Rock and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the Rock may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Rock employees, volunteers, and program participants and their families. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the Rock or participation in Rock programming (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the Rock, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Rock, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any Rock program.

I Agree
 to ASSUMPTION OF THE RISK AND WAIVER OF THE LIABILITY RELATED TO CORONAVIRUS/COVID-19

 

MEDIA RELEASE:

We hereby voluntarily release and forever allow On The Rock Ministries, Inc., to use, at its sole discretion, any and all photographic materials, and/or video materials taken of participant, in any manner On The Rock Ministries, Inc. deems suitable. We fully understand that this may include, but not be limited to, use of said material in a magazine, newspaper, newsletter, flyer, brochure, promotional literature, news programs, documentaries or other type of publication

I Agree
 to MEDIA RELEASE

 

MEDICAL RELEASE: 

In the event that I cannot be reached in an emergency, I hereby give permission to any licensed physician, surgeon, clinic, or hospital to secure proper treatment, and to order anesthesia, for my child/myself as named above.

I Agree
 to MEDICAL RELEASE

First Camp Rock All-star Name

First Name*

Middle Name

Last Name*

Phone*
First Camp Rock All-star Date of Birth*
I certify that I am 18 years of age or older
First Camp Rock All-star Information
Preferred method of communication?
E-mail
Phone
Text

School

Teacher

Age

How do you think this program might help your child?

START DATE OF PROGRAMS

All-Star Reading Club Training will be held Thursday, September 30th and October 7th, 4-6 pm in the
Rock's Education Center, 309 W. Hensley Bvld.

Parent Meeting: Monday or Tuesday, October 11th or 12th, 5:45PM, Rock's Education Center, 309 W. Hensley Bvld.

Question? Give us a call 918-336-2636 or email the staff at staff@rockbville.org

First Camp Rock All-star Signature*
Second Camp Rock All-star Name

First Name*

Middle Name

Last Name*
Second Camp Rock All-star Date of Birth*
Second Camp Rock All-star Information
Preferred method of communication?
E-mail
Phone
Text

School

Teacher

Age

How do you think this program might help your child?

START DATE OF PROGRAMS

All-Star Reading Club Training will be held Thursday, September 30th and October 7th, 4-6 pm in the
Rock's Education Center, 309 W. Hensley Bvld.

Parent Meeting: Monday or Tuesday, October 11th or 12th, 5:45PM, Rock's Education Center, 309 W. Hensley Bvld.

Question? Give us a call 918-336-2636 or email the staff at staff@rockbville.org

Third Camp Rock All-star Name

First Name*

Middle Name

Last Name*
Third Camp Rock All-star Date of Birth*
Third Camp Rock All-star Information
Preferred method of communication?
E-mail
Phone
Text

School

Teacher

Age

How do you think this program might help your child?

START DATE OF PROGRAMS

All-Star Reading Club Training will be held Thursday, September 30th and October 7th, 4-6 pm in the
Rock's Education Center, 309 W. Hensley Bvld.

Parent Meeting: Monday or Tuesday, October 11th or 12th, 5:45PM, Rock's Education Center, 309 W. Hensley Bvld.

Question? Give us a call 918-336-2636 or email the staff at staff@rockbville.org

Fourth Camp Rock All-star Name

First Name*

Middle Name

Last Name*
Fourth Camp Rock All-star Date of Birth*
Fourth Camp Rock All-star Information
Preferred method of communication?
E-mail
Phone
Text

School

Teacher

Age

How do you think this program might help your child?

START DATE OF PROGRAMS

All-Star Reading Club Training will be held Thursday, September 30th and October 7th, 4-6 pm in the
Rock's Education Center, 309 W. Hensley Bvld.

Parent Meeting: Monday or Tuesday, October 11th or 12th, 5:45PM, Rock's Education Center, 309 W. Hensley Bvld.

Question? Give us a call 918-336-2636 or email the staff at staff@rockbville.org

Fifth Camp Rock All-star Name

First Name*

Middle Name

Last Name*
Fifth Camp Rock All-star Date of Birth*
Fifth Camp Rock All-star Information
Preferred method of communication?
E-mail
Phone
Text

School

Teacher

Age

How do you think this program might help your child?

START DATE OF PROGRAMS

All-Star Reading Club Training will be held Thursday, September 30th and October 7th, 4-6 pm in the
Rock's Education Center, 309 W. Hensley Bvld.

Parent Meeting: Monday or Tuesday, October 11th or 12th, 5:45PM, Rock's Education Center, 309 W. Hensley Bvld.

Question? Give us a call 918-336-2636 or email the staff at staff@rockbville.org

Sixth Camp Rock All-star Name

First Name*

Middle Name

Last Name*
Sixth Camp Rock All-star Date of Birth*
Sixth Camp Rock All-star Information
Preferred method of communication?
E-mail
Phone
Text

School

Teacher

Age

How do you think this program might help your child?

START DATE OF PROGRAMS

All-Star Reading Club Training will be held Thursday, September 30th and October 7th, 4-6 pm in the
Rock's Education Center, 309 W. Hensley Bvld.

Parent Meeting: Monday or Tuesday, October 11th or 12th, 5:45PM, Rock's Education Center, 309 W. Hensley Bvld.

Question? Give us a call 918-336-2636 or email the staff at staff@rockbville.org

Seventh Camp Rock All-star Name

First Name*

Middle Name

Last Name*
Seventh Camp Rock All-star Date of Birth*
Seventh Camp Rock All-star Information
Preferred method of communication?
E-mail
Phone
Text

School

Teacher

Age

How do you think this program might help your child?

START DATE OF PROGRAMS

All-Star Reading Club Training will be held Thursday, September 30th and October 7th, 4-6 pm in the
Rock's Education Center, 309 W. Hensley Bvld.

Parent Meeting: Monday or Tuesday, October 11th or 12th, 5:45PM, Rock's Education Center, 309 W. Hensley Bvld.

Question? Give us a call 918-336-2636 or email the staff at staff@rockbville.org

Eighth Camp Rock All-star Name

First Name*

Middle Name

Last Name*
Eighth Camp Rock All-star Date of Birth*
Eighth Camp Rock All-star Information
Preferred method of communication?
E-mail
Phone
Text

School

Teacher

Age

How do you think this program might help your child?

START DATE OF PROGRAMS

All-Star Reading Club Training will be held Thursday, September 30th and October 7th, 4-6 pm in the
Rock's Education Center, 309 W. Hensley Bvld.

Parent Meeting: Monday or Tuesday, October 11th or 12th, 5:45PM, Rock's Education Center, 309 W. Hensley Bvld.

Question? Give us a call 918-336-2636 or email the staff at staff@rockbville.org

Ninth Camp Rock All-star Name

First Name*

Middle Name

Last Name*
Ninth Camp Rock All-star Date of Birth*
Ninth Camp Rock All-star Information
Preferred method of communication?
E-mail
Phone
Text

School

Teacher

Age

How do you think this program might help your child?

START DATE OF PROGRAMS

All-Star Reading Club Training will be held Thursday, September 30th and October 7th, 4-6 pm in the
Rock's Education Center, 309 W. Hensley Bvld.

Parent Meeting: Monday or Tuesday, October 11th or 12th, 5:45PM, Rock's Education Center, 309 W. Hensley Bvld.

Question? Give us a call 918-336-2636 or email the staff at staff@rockbville.org

Tenth Camp Rock All-star Name

First Name*

Middle Name

Last Name*
Tenth Camp Rock All-star Date of Birth*
Tenth Camp Rock All-star Information
Preferred method of communication?
E-mail
Phone
Text

School

Teacher

Age

How do you think this program might help your child?

START DATE OF PROGRAMS

All-Star Reading Club Training will be held Thursday, September 30th and October 7th, 4-6 pm in the
Rock's Education Center, 309 W. Hensley Bvld.

Parent Meeting: Monday or Tuesday, October 11th or 12th, 5:45PM, Rock's Education Center, 309 W. Hensley Bvld.

Question? Give us a call 918-336-2636 or email the staff at staff@rockbville.org

Camp Rock All-star Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Preferred method of communication?
E-mail
Phone
Text

School

Teacher

Age

How do you think this program might help your child?

START DATE OF PROGRAMS

All-Star Reading Club Training will be held Thursday, September 30th and October 7th, 4-6 pm in the
Rock's Education Center, 309 W. Hensley Bvld.

Parent Meeting: Monday or Tuesday, October 11th or 12th, 5:45PM, Rock's Education Center, 309 W. Hensley Bvld.

Question? Give us a call 918-336-2636 or email the staff at staff@rockbville.org

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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