GLLM Day Camp Registrations 2023

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Camper's Name (first, last) *

Date of Birth *

YYYY

Gender

Pronouns

Age *

Grade completed in 2023 *

T-shirt size *

Youth XS

Youth S

Youth M

Youth L

Youth XL

Adult S

Adult M

Adult L

Parent/Guardian(s) *

Address *

Phone (home) *

Phone (work) *

Phone (cell)

Email *

By checking yes, you give permission for your child to attend the Green Lake Lutheran Ministries Day Camp Program,
taking part in the normal program activities. You authorize the camp to secure a doctor to provide
any necessary emergency medical care. *

Yes

By checking yes, you give permission for the use of photographs, video, and electronic images including your child in camp promotion.
*

Yes

E-Signing (type your name below) *

By participating in programs, services, and activities of Green Lake Lutheran Ministries (GLLM),
you agree to the following: On behalf of yourself and your children, you hereby release, covenant not to
sue, discharge, and hold harmless GLLM, its employees, agents, and representatives, of and from all
liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating to your
participation in our programs, services or activities. You understand and agree that this release includes
any claims based on the actions, omissions, or negligence of this organization, its employees, agents,
and representatives, whether a COVID-19 infection occurs before, during, or after participation in any
hosted or programmed event by GLLM.

(E-SIGN BY TYPING YOUR NAME BELOW)

Family Doctor name/phone *

Emergency Contact name/phone (relationship to camper) *

Allergies *

EpiPen needed (GLLM does not provide EpiPen) *

Dietary Restrictions? *

Please list any routine medications
camp staff will have to administer,
including dosage and directions:
*If you would like to go over medication with
the individual administering it, please let the
Local Program Coordinator know. *

Date of last Tetanus shot. *

Camper up to date on immunizations? *

Yes

Is there any other information that we should know about your camper in order to best serve them during the day camp week? *

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