Summer Camp 2019 Registration

Saint Raphael Catholic School

Summer Camps

Rising 1st-Rising 8th Graders

SESSION

CAMP NAME

Session 1A

June 10-14       9:00-12:00

Session 1B

June 10-14       12:45-3:45

Session 2A

June 17-21     9:00-12:00

Session 2B

June 17-21     12:45-3:45

Session 3A

June 24-28     9:00-12:00

Session 3B

June 24-28     12:45-3:45

There is a $25.00 NON-REFUNDABLE Deposit Fee per Camp due with Registration.

# of Camps _______ x $125.00 – Deposit Fee = Balance Due _____________

(Example:  1 Camp @ $125.00 - $25.00 Deposit = $100.00 Balance Due)

                                                                    My child will need:

_______ Before Care ($5.00 per day)      

SRCS CAMP REGISTRATION


Camper’s Name _________________________________________            Male           Female

Address ___________________________________________________________________

__________________________________________________________________________

Camper’s Birth Date ________________________________________

    

Grade in August, 2019 _______________

Parent/Guardian 1 __________________________________________________________

        

Cell # ____________________________________

Address_____________________________________________________________________        

Daytime # ________________________________

Email Address _____________________________________________

Parent/Guardian 2 __________________________________________        

Cell # ___________________________________

Address _____________________________________________________________________

Daytime # _______________________________

Email Address _____________________________________________


Family Physician _____________________ Address _________________________________

Phone # ___________________________________

Dentist/Orthodontist  __________________ Address _________________________________

 

Phone # ___________________________________

Medical/Hospital Insurance Carrier

____________________________________________________________________________

Health History (circle all that apply)

           

        convulsions                asthma          bleeding/clotting disorder        allergies

____________________________________________________________________________

Restrictions on physical activity

____________________________________________________________________________

Current medications

 

____________________________________________________________________________

Other conditions of which camp staff should be aware:

 

____________________________________________________________________

In addition to Parent/Guardian names listed above, these person(s) have permission to pick up my child from camp. I understand that my child will not be allowed to leave with any other person without authorization from Parent/Guardian, and that the person picking up my child will show identification.

Name ________________________________________________________________

Phone # ____________________________   Relationship _____________________________

Name ________________________________________________________________

Phone # ____________________________   Relationship  ____________________________

____________________________________________________________________________

Parent/Guardian Signature                                                               Date