Summer Camp Registration 2019
Please fill out a separate form for each participating child
Child's Name *
Your answer
Date of Birth *
Your answer
Child's Medical Conditions and Allergies *
Your answer
Parent Guardian Name
Your answer
Parent Guardian Phone Number
Your answer
Parent Guardian Email Address
Your answer
Second Parent/Guardian
Your answer
Second Parent/Guardian Phone Number
Your answer
Second Parent/Guardian Email Address
Your answer
Emergency Contact Name/Phone Number
Your answer
Waiver Part 1: As a parent or guardian of the child whose name appears above, I hereby give my consent for said child to participate in St. Pauls United Church of Christ Summer Camp at any time from July 1, 2019, to August 2, 2019. I understand that insurance of any kind will not be provided by St. Pauls United Church of Christ for accidents or injuries that may occur, from any cause whatsoever, in connection with Summer Camp. I agree to relieve from any responsibilities, and to hold harmless, St. Pauls United Church of Christ, its camp counselors, employees, and any other supervisors of Summer Camp whatsoever that may occur in connection with said activity. Please type your name below as your signature and submit the form. Thank you!
Your answer
Waiver Part 2: As a parent or guardian of the child whose name appears above, I hereby give my consent for said child to participate in St. Pauls United Church of Christ off property trips to local parks, etc. at any time from July 1, 2019, to August 2, 2019. I understand that insurance of any kind will not be provided by St. Pauls United Church of Christ for accidents or injuries that may occur, from any cause whatsoever, in connection with any trips or outings. I agree to relieve from any responsibilities, and to hold harmless, St. Pauls United Church of Christ, its Camp Counselors, employees, and any other supervisors of such trip or outings whatsoever that may occur in connection with said activity. Please type your name below as your signature and submit the form. Thank you!
Your answer
Waiver Part 3: In the event of a medical emergency occurring to my child, I hereby authorize St. Pauls United Church of Christ, its CampCounselors and/or employees to act in loco parentis to my child. These individuals may authorize all necessary medical and/or surgical procedures that the medical authorities deem vital for the health of my child. I understand that every effort will be make to contact me immediately, and that medical or surgical procedures will be implemented only in the event that I cannot be contacted. Please type your name below as your signature and submit the form. Thank you!
Your answer
Waiver Part 4: I grant permission for St. Pauls United Church of Christ to use unidentified photograph(s) of my child for church-related programs or other print materials and display boards, as well the St. Pauls United Church of Christ website and Facebook page. Please type your name below as your signature and submit the form. Thank you!
Your answer
Camp Dates Sign Up-Full Day *Please select all days that your child will be attending camp. Please note the difference between Full day (9:00am -3:00pm) and Half day (9:00am to Noon). You may pick whatever combination of dates that you would like.
Half Day Dates
Before Camp Care 8:00am-9:00am
After Camp Care 3:00pm-5:00pm
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