PAC @ The Mount Camp Application
Performing Arts Summer Camp
1172 Lawwrence Street, Camden NJ 08102
Mount Calvary Missionary Baptist Church, Christian Education Building
Camper Details
(Please note: Three (3) year old children are only accepted in the camp when there are older siblings enrolled in the camp at the same time. [There are limited spaces for 3 year olds] Also a new application must be completed for each child individually)
Camper's Information
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Camp Session
*
Session One: July 8 - July 19 - $400
Session Two: July 22 - August 2 - $400
Session Three: August 5 - August 16 - $400
Does the camper have any allergies or sensitivities that staff need to be aware of?
*
Has the camper undergone any operations or sustained any serious injuries
*
If Yes, Please Describe
Is the camper currently taking any medications? If yes, please include the name of the medication (brand name and generic name) dosages, times taken, and reason below.
*
Please specify below any dietary restrictions, including vegetarian/vegan, lactose or gluten intolerance, etc.
*
Health Declaration: I DECLARE UNDER PENALTY OF PERJURY, UNDER THE LAWS OF THE STATE OF NEW JERSEY, THAT TO THE BEST OF MY KNOWLEDGE, INFORMATION AND BELIEF MY CHILD IS IN GOOD PHYSICAL HEALTH AND IS CAPABLE OF PARTICIPATING IN CAMP ACTIVITIES, INCLUDING SWIMMING, FIELD TRIPS AND OTHER VIGOROUS PHYSICAL ACTIVITY. I HEREBY AUTHORIZE MY CHILD TO PARTICIPATE IN SUCH ACTIVITIES.
*
PLEASE TYPE NAME AS ELECTRONIC SIGNATURE
Parental/Guardian Information
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Relation to Camper
*
Best Email Contact
*
example@example.com
Please make checks payable to:
Mount Calvary Missionary Baptist Church
I am using the Childcare Care Assistance Program (CCAP)? Performing Arts Camp at the Mount NJCCIS ID # 714956; CAMP DOH ID: 963096; PHONE # 856-966-9400
*
Yes
No
IN CASE OF EMERGENCY, PLEASE LIST AT LEAST 2 EMERGENCY CONTACTS (Name, Phone Number, Email, and Relationship to Camper)
*
TRANSPORTATION RELEASE: I hereby give permission for the transportation of my child by modes of transportation agreed to by the camp organizers in relation to PAC @ THE MOUNT.
*
YES
NO
FILM RELEASE: I hereby give permission for photos and quotes of my child to be used for publicity purposes in relation to PAC @ THE MOUNT.
*
YES
NO
*PLEASE PROVIDE IMMUNIZATION RECORDS UPON REGISTRATION ENTER ANY RELIGIOUS EXEMPTIONS BELOW
Exemptions
Submit
Should be Empty: