Summer Daze Enrollment 2024

Summer Daze Enrollment 2024

WCCPC Children's and Youth Ministries
July 11, 18, 25 August 1*

12:00pm - 3pm* Unless otherwise advertised
Child/Youth Name

First NameLast NameSuffix
Gender
Birth Date

MonthDayYear
Grade completed end of 2023-24 school year
School Attended 2023-24 school year
Child/Youth email (if applicable)
example@example.com
Child/Youth cell number (if applicable)

Area CodePhone Number
Mother's Name
Mother's cell number

Area CodePhone Number
Mother's email
example@example.com
Father's Name
Father's cell number

Area CodePhone Number
Father's email
example@example.com
Child/Youth residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Contact

First NameLast Name
Relationship to child/youth
Emergency Contact phone number

Area CodePhone Number
Child/Youth Release-Name of person(s) authorized to pick up children (also indicate relationship and telephone number)
ID will be required at time of pick up
Primary Care Physician's Name

First NameLast Name
Primary Care Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Care Physician's Office Telephone Number

Area CodePhone Number
Is the child/youth covered by medical insurance?

YESNO
Insurance Company Name
Insurance Subscriber ID#:
Insurance Group #:
Allergies/Medical notes/concerns
By submitting this completed form, I give White Clay Creek Presbyterian Church permission to seek medical attention in case of emergency.
Church home/affiliation (if any)
Any other concerns/questions
A Summer Daze team member will be in touch to answer any questions.
By submitting this form, I acknowledge that Summer Daze photos may appear on the WCCPC website or posted within the church and understand that under no circumstances will children in these photos by identified with names or any personal information. I reserve the right to have any photo that includes my child removed upon request.*

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Summer Daze Enrollment 2024

July 11, 18, 25 August 1*