Student Name * Street Address City State Zip Date of Birth * Grade Entering in Fall 2019 * Parent or Guardian Name * Relationship to Camper * Select one Mother Father Guardian Grandparent Other Occupation E-Mail * Phone Number * Secondary Parent or Guardian Name * Relationship to Camper * Select One Mother Father Guardian Grandparent Other Email * Alternate Phone Number * Person(s) autorized to pick up my child Emergency Contact Name * Emergency Contact Relationship To Camper * Emergency Contact Phone Number * Health History: Last Tetanus Shot * Health History: Immunizations (All immunizations required for school are up to date * Select One Yes No Health History: Date of Last Health Examination * Health History: Medications (if yes, please fill out dosage/schedule below) * Select One Yes No Medication Permission: Do you give consent for these over-the-counter medications: Tylenol, Ibuprofen, Benadryl, Other * Select One Yes No I will specify below Medical Allergies * Select One Yes No Food Allergies * Select One Yes No Camper’s Insurance Company * Policy Number * Insurance Company Phone Number * Insurance Company Address * Primary Physician Name * Primary Physician Phone Number *
To the best of my knowledge, all registration and health information is correct. Any images recorded while participating in camp activities may be used for the camp’s promotion free of any claims. I give permission for my child to participate in all camp activities except as noted and agree that the camp or its staff will not be held responsible for any accidents or personal injury arising therefrom. In the event of an emergency, I give permission to the medical personnel or staff selected by the camp to secure and/or administer any medical or emergency treatment, including hospitalization, deemed necessary for my child. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes. I give permission to the camp to arrange necessary transportation for my child. I understand that St. John’s Lutheran Church of Hatboro is not responsible for medical costs due to illness or injury while at this event, and I agree to cover all costs associated with any such injury. I am the primary carrier of the accident/health insurance. If all immunizations required for school are not up to- date, I understand and accept the risks to my child from not being fully immunized. Parent Signature ( Full name or Initials Required) * Date * I would like to volunteer to teach, lead or help: crafts games small group leader science sign-in table snacks large-group time lesson preparation Photo Release: I permit my child’s photo to be used in displays in the church * Select One Yes No Photo Release: In the church’s weekly and monthly newsletters and on the website * Select One Yes No Photo Release: My child’s first and last name may be used. * Select One Yes No
In case of a medical emergency, I give my consent for my child to be transported to the nearest hospital, and for the attending physician to administer any necessary medical treatment. I give St. John’s education staff permission to administer basic first aid (band-aids, etc) to my child. Please note: The education staff will not administer any medication without written consent form the child’s parent on the day the medication is to be administered. Whenever possible, please give your child any needed medications before bringing him/her to class.
If your child has been issued an Epi-pen, please note this under Special Needs on the registration form. Parent Signature: (Full name or Initial required) * Date: * 1 + 0 = ? Please prove that you are human by solving the equation *