Camp GLOW Registration

Register For A Camp

Camper Information

Sibling Information

Additional Siblings

Bereavement History

Camper Health Information

Emergency Contact Information

Parent/Guardian Information

Parent/Guardian Health Information

Additional Adult Attending Camp

Additional Adult Health Information

Media Consent*

By signing this form you are giving consent to SSM Health at Home, its affiliates, agents, and/or news media, to use your name, image and likeness and/or any interview statements from you in its publications, advertising, or other media activities. This consent includes but is not limited to: Audio Recording, Motion Pictures, Photographs, Electronic Images, Live Broadcast, Interview/Print, and may be obtained by SSM Health at Home or by a media representative directly.

By signing this authorization, you waive any right to compensation for such uses, and you and your successors or assigns also release and hold harmless SSM Health at Home from and against any claim for any injury in connection with the use, copying, distribution, or display of your image, voice, likeness, name, or any other identifying characteristics in the broadcast or publication and any compensation resulting from the activities authorized by you in this authorization.

If you change your mind at any time, you can revoke this authorization by sending a written notice stating you are revoking your authorization to SSM Health at Home Marketing Department (2802 Walton Commons Lane, Madison, WI 53718). It will be effective upon receipt.