Summer Day Camp Registration

July 8-12, 2024 - 9AM to 3PM Each Day

Child's Name

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Address

Include mailing address on line 2 if different

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone (Primary)

(###)

###

####

Cell Phone

(###)

###

####

Work Phone

(###)

###

####

Email

Age Information

Birth Date

MM

DD

YYYY

Last grade completed in school

Medical Information

Medical or other information we need to know. (Please include any allergies.)

Emergency Contact 1 Name

First Name

Last Name

Emergency Contact 1 Phone Number

(###)

###

####

Emergency Contact 2 Name

(optional)

First Name

Last Name

Emergency Contact 2 Phone Number

(optional)

(###)

###

####

Dismissal Information

Who may pick up your child at the end of each Day Camp day?

Does your child attend Sunday School? If so where?

If your child is visiting our church, who is he/she a guest of?

May we have permission to photograph your child?

Yes

No

May we have permission to use your child's photograph for the purpose of promotion?

Yes

No