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Village at Home
What: Antiochian Village Day of Camp
Whom: Children Ages 9 to 17
When: Saturday, March 17, 2018 from 9 AM - 8 PM
Where: (MAILING ADDRESS) St. George's Antiochian Orthodox Church 237 Long Hill Road, Little Falls, NJ
Registration DEADLINE: February 26th, 2018
Name of Child/ Date of Birth/Grade *
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Name of Child/ Date of Birth/ Grade
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Name of Child/ Date of Birth/ Grade
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Home Parish (Name of Parish and Location) *
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Does your child/children (list name) have food allergies? If so, please list below: *
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Consent
My child/children has my permission to participate in the "Village at Home" program at St. George Antiochian Orthodox Church in Little Falls, NJ on Saturday, March 17th, 2018 from 9 AM- 8 PM and all of the activities included during the course of this program. I understand that reasonable precautions will be taken to safeguard his/her health and safety, and that I will be notified as soon as possible in case of an emergency. Also, I shall not hold liable any Orthodox Church, its clergy, Council members, staff, volunteers, the Antiochian Orthodox Christian Archdiocese of North America, the Antiochian Village, nor any individual lending or giving his/her private property to be used in connection with this event for any illness or accident. If I am unable to be reached and occasion demands, I further authorize any treatment and hospital care advisable under the supervision of licensed medical physician. Such treatment may include X-ray, examination, anesthetic, medical denial, or surgical diagnosis.
PARENT- PRINT NAME AND DATE *
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PARENT- ELECTRONIC SIGNATURE for the above info. *
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Address of Child/Children and Phone Number *
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Emergency Contact (Name, Relationship, and Phone Number) *
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Emergency Contact (Name, Relationship, and Phone Number)
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We ask for a donation of $10 for one child and $20 for two or more siblings which will cover all meals and events for the day! Please complete this form by Saturday, February 26th, 2018. Thank you!
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