Camp Refuel Registration

Camper information

Emergency Contact Information

Please enter the name of the parent or guardian who should be contacted in the case of an emergency.

Medical Information

Media Release

I hereby grant the Light the Night Ministries, its directors, officers, employees, agents, and designers (collectively “LTN”) non-revocable permission to capture my image and likeness in videotapes, motion pictures, recordings, or any other media (collectively “Images”). I acknowledge that LTN will own such Images and further grant the LTN permission to copyright, display, publish, distribute, use, modify, print and reprint such Images in any manner whatsoever related to LTN business, including without limitation, publications, advertisements, brochures, web site images, or other electronic displays and transmissions thereof. I further waive any right to inspect or approve the use of the Image by the LTN prior to its use. I forever release and hold the LTN harmless from any and all liability arising out of the use of the Images in any manner or media whatsoever, and waive any and all claims and causes of action relating to use of the Images, including without limitation, claims for invasion of privacy rights or publicity.


I agree for my child listed on this form to attend the Camp Refuel weekend and attest to the accuracy of all information by my signature in the box above. I also authorize Camp Willow Springs and Light the Night Ministries to act in their best judgment in any emergency requiring medical attention. I release Camp Willow Springs and Light the Night Ministries from liability for any injury or illness incurred at camp.