Summer day camps reg.indd

Child’s Name: ______________________________________________________________________________________________________________EMERGENCY INFORMATIONIn case of an emergency, notify: (1) Name: __________________________________________________________________________________________________________________ Phone: (_____)_______________________ Alt. Phone: (_____)______________________ Relationship: _______________________________________________________________________________________________________________ Last Tetanus Shot _______________Chicken Pox ___________________ (2) Name: __________________________________________________________________________________________________________________ Phone: (_____)_______________________ Alt. Phone: (_____)______________________ Relationship: _______________________________________________________________________________________________________________ Name of family physician: ______________________ _______________________________________________________________________________ Phone: ___________________________________________________________________________________________________________________ Do you carry family medical/hospital insurance? Yes No Carrier Name: ____________________ Phone: (_____)______________________ Penicillin ______________________Amoxicillin _____________________ Group Policy Number: _________________________ ______________________________________________________________________________ Name Of Insured: ___________________________ (Give approximate dates of occurrences, mild or severe.) Heart Defect/Disease ________________________________________________________________________________________________________ Convulsions _______________________________________________________________________________________________________________ Bleeding/Clotting Disorders ___________________________________________________________________________________________________ Asthma ___________________________________________________________________________________________________________________ Allergic to Red Dye __________________________________________________________________________________________________________ Lactose Intolerant ___________________________________________________________________________________________________________ Psychiatric Limitations ________________________________________________________________________________________________________ Please describe any mental limitations: __________________________________________________________________________________________ Please describe any physical limitations: _________________________________________________________________________________________ Any allergies (food, animals, insects, etc.): _______________________________________________________________________________________ Are there any activities from which the camper should be restricted? ___________________________________________________________________THIS FORM MUST BE SIGNED TO REGISTER I understand every effort will be made to contact the parent(s)/guardian(s) of the child named on the Medical Release Form. In the event I cannot be reached in such a situation, I hereby give permission to the Cathedral of Praise Camp Director to hospitalize and secure proper treatment for my child.
Release made this date of ______________________, 20_____, by the undersigned as in consideration of the permission granted my child by Cathedral of Praise to participate in recreational events, I hereby release and discharge Cathedral of Praise, its agents, employees and offi cers from all claims, demands, actions, and judgments which the undersigned’s heirs, executors, administrators, or assigns may have or claim to have against Cathedral of Praise, its successors or assigns, for all personal injuries, known or unknown, which my child named on the Medical Release Form has or may incur by participating in any of the activities sponsored by Cathedral of Praise.
I have read this release and understand all of its items. I execute this release voluntarily and with full knowledge of its signifi cance. _________________________________________________ 3790 Ashley Phosphate Road • N. Charleston, SC 29418 • 760-2626 • Fax: 760-2629 • www.cathedralofpraise.org All camps must be paid in full at the time of registration to secure your child’s spot. Camp tuition includes a $50.00 non-refundable application fee. No refunds will be given for cancellation unless we are notifi ed 7 days before the scheduled camp start date.
Child’s Name __________________________________________________________________________________________ Address: ______________________________________________________________________________________________ City/State/Zip: _________________________________________________________________________________________ Birth Date: _________________ Age: ______ Male Female Parents’ Names: _______________________________________________________________________________________ Home Phone: (_____)__________________ Work Phone: (_____)___________________ Cell Phone: (_____)____________________ Beeper/Pager: (_____)__________________ Email Address: _________________________________________________________________________________________ Please check child’s T-shirt size: S M L Adult S Adult M Adult L Adult XL

Source: http://www.cathedralofpraise.org/uploads/camps_reg2.pdf