Central UMC Summer "Compassion Camp" Registration Form

Central UMC "Live it Out" VBS Registration Form

9:00 am - 12:00 pm Wednesdays June 11, 18, 25, July 2 & 9 at Central UMC, 200 E. Marion St. Shelby, NC. Contact caroline@cumcshelby.org with any questions.
STUDENT INFORMATION
Child Name*

First NameLast Name
Birthdate *

MonthDayYear
Date
Grade completed *
T-shirt Size
YesNo

Household Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Adult Contact Name*
Primary Adult Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Primary Adult Email*
example@example.com
Secondary Adult Contact Name
Secondary Adult Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Adult Email
example@example.com
EMERGENCY CONTACT
Emergency Contact Name*
Relationship to child*
Emergency Contact Number*
Format: (000) 000-0000.
AUTHORIZED PICKUP ADULTS

Please list the first and last names and phone numbers off ALL adults who are allowed to pick up this child. The child will only be released to these people unless notification has been given to the church office or Caroline Scism.
Authorized Pickup #1 Name*
Relationship to child*
Authorized Pickup #1 Phone Number*
Format: (000) 000-0000.
Authorized Pickup #2 Name
Relationship to child
Authorized Pickup #2 Phone Number
Format: (000) 000-0000.
Medical Information
Please list any allergies for your child/children -- or type "none" if there are none*
YesNo
Please list any other medical concerns for your child/children
Additional Information
YesNo
June 11June 18June 25July 2July 9
Is there any additional helpful information we should know?
By submitting this form, I ackowledge I have read and understand the above information.
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Central UMC "Live it Out" VBS Registration Form