Vacation Bible School Registration & Health Form
Bethlehem Lutheran Church will partner with Fairport United Methodist Church and staff from Camp Mount Luther to once again host a Vacation Bible School day camp for children this summer. It will be held July 23-July 27 from 9:00AM-3:00PM. Programs will be available for children who have just completed kindergarten through sixth grade.

Openings will be filled on a first come, first served basis. The cost is $50 per camper ($25 for additional siblings). Please submit payment via check made out to Bethlehem Lutheran Church with "VBS" in the Memo line to BLC's office. Contact Katie at katie.kreutter@blcfairport.org or 585-223-0634 with any questions.

Please use this form to register your child for participation. Be sure to click SUBMIT at the bottom of your completed form.

Child's first and last name *
Your answer
Age *
Your answer
Date of Birth *
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Grade for 2017-2018 school year *
Your answer
Home Address (House Number/Street/City/State/Zip) *
Your answer
Gender *
Your answer
T-shirt size *
Parent/Guardian First and Last Name *
Your answer
Preferred Phone *
Your answer
Alternate Phone
Your answer
E-mail Address *
Your answer
Second Parent First and Last Name
Your answer
Second Parent Preferred Phone
Your answer
Second Parent Alternate Phone
Your answer
Second Parent E-mail Address
Your answer
Food Allergies and Diet Restrictions:
Your answer
Other Allergies (including medications, plants, and insects):
Your answer
Indicate whether the camper’s immunizations required for school are up to date. (Can attach a list) *
Provide the date (month/year) of last tetanus shot: *
Your answer
Does insurance require MD approval prior to care? *
If so, indicate phone number to call:
Your answer
Medical Insurance Carrier/Plan Name & Group Number: *
Your answer
Insurance ID Number: *
Your answer
Parent/Guardian Name on Policy: *
Your answer
Name of friend or relative (not living at same address): *
Your answer
Relationship: *
Your answer
Preferred Phone *
Your answer
Alternate Phone
Your answer
“Camp” refers to personnel at congregation and/or the Camp Mount Luther staff. 1) I hereby give consent for camp personnel to give over-the-counter medications should it be necessary. I understand that Camp Mount Luther and its employees are not responsible for untoward effects of nonprescription medications. 2) I give the camp permission to dispense my child’s prescription medication as listed. 3) I agree that if immediate care is deemed necessary, and I was not able to be contacted, I give camp personnel the authority to act in my absence. I hereby agree to indemnify and hold harmless from any expense or claims of any nature Bethlehem Lutheran Church and its representatives. I understand that I am responsible for any charges that may be incurred. 4) I hereby give permission to my child(ren) to participate in the programs and activities of Day Camp. In the event walks in the Village of Fairport are planned away from the church (ex. Potter Park) as part of the program under the direction of the camp administration, my child has my permission to participate in such activities. 5) Any photos or video recordings taken in which my child appears may be used for promotion of camp and its related entities free of any claims. 6) This completed form may be photocopied for trips out of camp. Have you read and understood this statement? *
Please enter full name of authorizing parent. (You may be asked to sign a paper copy of this release on the first day of camp.) *
Your answer
Today's Date *
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