2023 Summer Camp Registration

Summer Camp Registration

DNA Community Center 2023
We are so happy you are registering your children for this year's camp. Please read the following carefully:

1. Camp for kids going into 7th & 8th grades is for 1 week from June 12th to June 16th (M-F) from 11 am to 4 pm. There are limted spots available.

2. Camp for kids going into 1st through 6th is for 3 weeks starting on June 26th until July 14th. It runs daily (M-F) from 10:30am to 1:00 pm

3. During registration you will be asked whether or not you need transportation to and from camp.

4. This camp is for kids in the Jonathan Alder and Fairbanks school districts.
Parent/Guardian Name*

First NameLast Name
Community*

Green MeadowsCanaan CommunitySuburbanPlain CityOther
What county do you live in?*

MadisonUnionOther
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Ethnicity*

Latino/HispanicWhiteBlackAsianNative AmericanOther
How many children are you registering for 1st through 6th camp?*
How many children are you registering for 7th & 8th camp?*
1st through 6th Camp

June 26th to July 14th
1st Child - Name

First NameLast Name
1st Child - Grade Going into 2023/24
1st Child - DOB

MonthDayYear
Date
T-Shirt Size*

Child - SmallChild - MediumChild - LargeAdult - SmallAdult - MediumAdult - LargeAdult - X-LargeAdult - 2X-Large
1st Child - Allergies

NoneFishShellfishPeanutsTree nutsSoyMilkWheatOther
1st Child - Current Medical Issues / Medications
2nd Child - Name

First NameLast Name
2nd Child - Grade going into 2023/24
2nd Child - DOB

MonthDayYear
Date
T-Shirt Size

Child - SmallChild - MediumChild - LargeAdult - SmallAdult - MediumAdult - LargeAdult - X-LargeAdult - 2X-Large
2nd Child - Allergies

NoneFishShellfishPeanutsTree nutsSoyMilkWheatOther
2nd Child - Current Medical Issues / Medications
3rd Child - Name

First NameLast Name
3rd Child - Grade going into 2023/24
3rd Child - DOB

MonthDayYear
Date
T-Shirt Size

Child - SmallChild - MediumChild - LargeAdult - SmallAdult - MediumAdult - LargeAdult - X-LargeAdult - 2X-Large
3rd Child - Allergies

NoneFishShellfishPeanutsTree nutsSoyMilkWheatOther
3rd Child - Current Medical Issues / Medications
4th Child - Name

First NameLast Name
4th Child - Grade going into 2023/24
4th Child - DOB

MonthDayYear
Date
T-Shirt Size

Child - SmallChild - MediumChild - LargeAdult - SmallAdult - MediumAdult - LargeAdult - X-LargeAdult - 2X-Large
4th Child - Allergies

NoneFishShellfishPeanutsTree nutsSoyMilkWheatOther
4th Child - Current Medical Issues / Medications
7th & 8th Grade Camp

June 12th to June 16th
1st Child - Name (7 & 8)

First NameLast Name
1st Child (7 & 8) - Grade going into 2023/24
1st Child (7 & 8) - DOB

MonthDayYear
Date
1st T-Shirt Size (7 & 8)

Child - SmallChild - MediumChild - LargeAdult - SmallAdult - MediumAdult - LargeAdult - X-LargeAdult - 2X-Large
1st Child (7 & 8) - Allergies

NoneFishShellfishPeanutsTree nutsSoyMilkWheatOther
1st Child (7 & 8) - Current Medical Issues / Medications
2nd Child - Name (7 & 8)

First NameLast Name
2nd Child (7 & 8) - Grade going into 2023/24
2nd Child (7 & 8) - DOB

MonthDayYear
Date
2nd T-Shirt Size (7 & 8)

Child - SmallChild - MediumChild - LargeAdult - SmallAdult - MediumAdult - LargeAdult - X-LargeAdult - 2X-Large
2nd Child (7 & 8) - Allergies

NoneFishShellfishPeanutsTree nutsSoyMilkWheatOther
2nd Child (7 & 8) - Current Medical Issues / Medications
3rd Child - Name (7 & 8)

First NameLast Name
3rd Child (7 & 8) - Grade going into 2023/24
3rd Child (7 & 8) - DOB

MonthDayYear
Date
3rd T-Shirt Size (7 & 8)

Child - SmallChild - MediumChild - LargeAdult - SmallAdult - MediumAdult - LargeAdult - X-LargeAdult - 2X-Large
3rd Child (7 & 8) - Allergies

NoneFishShellfishPeanutsTree nutsSoyMilkWheatOther
3rd Child (7 & 8) - Current Medical Issues / Medications
My family is currently eligible for free and/or reduced lunch at school*

YesNo
I understand my child's image may appear in D.N.A.'s social media accounts or newsletter.*

YesNo
I, the (Parent/Guardian Name) who completed this form, give permission to my above named child(ren)to attend the DNA Summer Camp Program, at Sharon Mennonite Church, located at 7675 Amity Pike, Plain City, OH 43064. I hereby release DNA, its Staff and volunteers from any and all liability arising from claims of any kind or nature whatsoever from my child’s participation in this program. I understand that the DNA staff may perform basic first aid; i.e. administering bandages, etc. We WILL NOT administer any medications. Sign below.
Parent/Guardian Name *

First NameLast Name
Signature of Parent/Guardian Listed above*

Clear
Transportation
Pick-up or drop-off?*

I give permission for my child(ren) to be picked up/dropped off by a school bus or other DNA sanctioned 15-passenger van.I prefer to provide my own transportation. My 1st - 6th grade child(ren) will be dropped off at 10:30 am and picked up daily by one of the following parent(s)/guardian(s) at 1:00 pm and/or 7th - 8th grade child(ren) will be dropped off at 11:00 am and picked up daily by one of the following parent(s)/guardian(s) at 4:00 pm.
(7th & 8th)*

I give permission for my child(ren) to be picked up/dropped off by a school bus or other DNA sanctioned 15-passenger van.I prefer to provide my own transportation. My child(ren) will be dropped off at 11:00 am and picked up daily by one of the following parent(s)/guardian(s) at 4:00 pm.
Parent/Guardian Name *

First NameLast Name
Signature of Parent/Guardian Listed above*

Clear
Emergency & Medical Authorization
If your child is injured/ill/needs to go home we should contact (after we try mom/dad/legal custodian guardian) : The people listed below also have the permission to sign my child out of the DNA Summer Camp located at Sharon Mennonite Church:
Person 1 - Name*

First NameLast Name
Person 1 - Relationship *
Person 1 - Cell #*
Please enter a valid phone number.
Person 2 - Name*

First NameLast Name
Person 2 - Relationship *
Person 2 - Cell #*
Please enter a valid phone number.
Physician Name
Physician Phone Number
Please enter a valid phone number.
Dentist Name
Dentist Phone Number
Please enter a valid phone number.
Preferred Hospital
Consent - Granting or Refusal
Granting or Refusal*

In the event reasonable attempts to contact me have been unsuccessful, I hereby give my consent for the administration of any treatment deemed necessary by the above Doctors or in the event the designated preferred practitioner is not available, by another licensed physician or dentist. If deemed necessary, the transfer of the child to the Hospital above or any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery.I DO NOT give my consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I wish the DNA authorities to take no action, but to what I list below.
Do this since I have refused to grant you medical authorization.
Parent/Guardian Name *

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Summer Camp Registration

1st through 6th Camp

7th & 8th Grade Camp

Transportation

Emergency & Medical Authorization

If your child is injured/ill/needs to go home we should contact (after we try mom/dad/legal custodian guardian) : The people listed below also have the permission to sign my child out of the DNA Summer Camp located at Sharon Mennonite Church:

Consent - Granting or Refusal