Camp360 Registration

JRC Camp360 
Jackson Revival Center Church
4566 Terry Road | Jackson, MS
(601) 948-1874
Cost: $265/camper
Includes lodging, meals, activities, and camp t-shirt.
*Please fill out a separate form for each camper*

Camper Info

Which Camp 360 is your child attending? *
Which Camp 360 is your child attending? *

Parent/Guardian Info

Relationship to Participant: *

Emergency Contact

Medical Conditions/Dietary Requirements

Camp Waiver

I hereby give my child permission to attend and participate in the Jackson Revival Center Church, Inc. Camp 360˚ for adolescent males. I hereby waive, release, and discharge any and all claims, demands, and causes of action against program officials, and Jackson Revival Center Church, Inc. of Jackson, MS and its agents, employees, and participants from any liability arising from any damages, property loss, or injury my child may sustain at Camp 360˚. I declare that the information provided to me above is acceptable and the information that I have provided is accurate and current.
I further consent to allow Jackson Revival Center Church, Inc. to provide routine health care, administer prescribed medications,and seek emergency medical treatment as needed. In the event I cannot be reached in an emergency, I hereby give my permission to the physician selected by the staff to secure and administer treatment, including hospitalization, for the participant named above. I understand that my insurance coverage is primary and I hereby accept all responsibilities for medical costs.
I hereby indicate that I have completed all components of this application, provided the necessary documentation, and I understand and all conditions therein.
The following box must be checked in order to participate in the Camp 360 Camp. *
Registration Fee *