Summer Camp

Please fill out a registration form for each child participating:

Name of Child:

Gender:

Grade:

Date of Birth:

Address:

City:

State:

Zip:

Mother's Name (or Guardian):

Phone:

Father's Name and Phone:

Parent Email:

Allergies:

Medical Issues?

Emergency Contact Name & Relationship:

Emergency Contact Phone:

Alternative Pickup Name and Relationship:

Alternative Pickup Phone:

I give my permission to the staff to seek medical attention for my child if necessary while participating in this camp. I understand that all necessary precautions will be taken for my child’s safety. I will not hold the church, its staff or those supervising liable. Fill in your name below to give permission:

What school does your child attend?

How did you find out about us?

Additional Comments: