Lighthouse Drama Camp Registration 2019
Registration for "Winne the Pooh Kids" Lighthouse Drama Camp at First United Presbyterian Church of Dale City, VA

July 1-12, 2019 (excluding July 4, 2019). Performances July 12 & July 13!

Music, Art, and Drama all afternoon!

Great teachers, creativity, and fun! A mini-musical in two weeks!
Full Name of Student *
Your answer
Age of Student: *
Your answer
Grade of Student: *
Home Church (Optional):
Home Address: *
Your answer
Parent Name (1): *
Your answer
Parent Cell Phone (1): *
Your answer
Parent Home Phone (1):
Your answer
Parent Email Address (1): *
Your answer
Parent Name (2):
Your answer
Parent Cell Phone (2):
Your answer
Parent Home Phone (2):
Your answer
Parent Email Address (2):
Your answer
I understand that this camp is from 1:00 PM to 4:00 PM July 1-12, 2019 (except July 4th, which is a holiday). *
I understand that I need to pack a healthy snack for my child each day. *
Does your child have any medical issues or concerns we should be aware of? (Please describe them below in as much detail as needed.)
Your answer
Is there anything else we should know to help us care for your child?
Your answer
I understand that this production will have two performances on Friday, July 12th at 7:00 PM and Saturday, July 13th at 2:00 PM. *
By electronically signing this permission form, you agree that any photographs and/or video taken of your child at or during Lighthouse Drama Camp are the property of First United Presbyterian Church (Dale City, VA) and may be used in future publications (print and electronic) as deemed appropriate. Note: Names of children will not be published with the photos. *
Persons to be contacted in case of emergency (other than parent or guardian) Name of Person 1: *
Your answer
Phone Number of Person 1: *
Your answer
Relationship to Child of Person 1: *
Your answer
Persons to be contacted in case of emergency (other than parent or guardian) Name of Person 2:
Your answer
Phone Number of Person 2: *
Your answer
Relationship to Child of Person 2: *
Your answer
Persons, other than a parent/guardian, (ID required) permitted to pick up my child are:
Your answer
Persons, other than a parent/guardian, (ID required) permitted to pick up my child are:
Your answer
Persons, other than a parent/guardian, (ID required) permitted to pick up my child are:
Your answer
Cost: $130 per camper. Please make checks out to "FUPCDC" and put "Drama Camp" in the memo line. Please drop off your payment, or mail your payment to: FUPCDC, 14391 Minnieville Road, Woodbridge, VA 22193. *
The undersigned gives permission for their child to participate in the above named activity and releases First United Presbyterian Church (Dale City, VA), their officers, employees, and agents from any liability whatsoever for any injury or death to person or loss or damage to property sustained by the undersigned for any member of his or her family in attendance, and the undersigned agrees to defend and indemnify First United Presbyterian Church (Dale City, VA), their officers, employees, and agents from any liability or loss they might sustain by reason thereof. In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician selected by the Pastor or Drama Director of First United Presbyterian Church to hospitalize, secure proper treatment for, and order injection, anesthesia, or surgery for my child as named above. Electronic Signature (Please type your full name below): *
Your answer
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