Summer Bible Camp
Event: June 23-27 from 5:55-8pm
Event Address: 83 S. Courtland St East Stroudsburg, PA 18301
Contact us at 570.421.3280 or esumc.childrens@gmail.com
Child's Name (First & Last) *
Your answer
Grade Entering This Fall *
Address *
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City *
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State *
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Zip Code *
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Parent/Guardian's Name (First & Last) *
Your answer
Parent/Guardian's Cell Phone *
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Email *
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Emergency Contact Person (First & Last) *
Your answer
Relation to child *
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Emergency Contact's Phone Number *
Your answer
East Stroudsburg United Methodist Church Photography Release FormParent/Guardian's Authorization
As the custodial parent/guardian of the participant named above, I give my permission to East Stroudsburg United Methodist Church Vacation Bible School to photograph my child in a group setting during Summer Bible Camp. The photos may be used by the church in the Church newsletter, displays, or on the Church website.
Parent Initials *
Your answer
Date: *
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Medical Release Form
Does your child have health insurance *
Name of health insurance *
Your answer
Name of Family Doctor *
Your answer
Phone Number *
Your answer
List any special needs your child might have:
Your answer
List any severe food or environmental allergies:
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Any activity restrictions
If yes, what activity
Your answer
Parent Medical and Liability Release Statement
I understand that in the event medical intervention is needed, an attempt will be made to immediately contact the persons listed on this form. In the event that we cannot be reached in an emergency during the activity dates shown on this form, I hereby give my permission to the EMT's, physical, or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or order an injection, anesthesia, or surgery form my child which is deemed medically necessary.
I understand all reasonably safety precautions will be taken at all times by East Stroudsburg UMC and its agents during the events and activities. I understand the possibility of unforeseen hazards and know that inherent possibility of losses, diseases or injuries incurred by my child.
Parent/Guardian's Signature *
Your answer
Date: *
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