Please Fill Out One Form Per Camper
Emergency Contact information
Adult 1 is
Please Select
Mother
Father
Legal Guardian
Emergency Contact
Please provide 1-2 legal guardians and one emergency contact
Name
*
First Name
Last Name
Adult 1 Cell Phone Number
*
Adult 1 Work Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Does Adult 1 have permission to Pick up?
*
Yes
No
Adult 2 is
*
Please Select
Mother
Father
Legal Guardian
Emergency Contact
Please provide 1-2 legal guardians and one emergency contact
Name
*
First Name
Last Name
Adult 2 Cell Phone Number
*
Adult 2 Work Phone Number
*
Adult Two's Address is the same as Adult 1
Yes
No
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Does Adult 2 have permission to Pick up?
*
Yes
No
Adult 3 is
*
Please Select
Mother
Father
Legal Guardian
Emergency Contact
Please provide 1-2 legal guardians and one emergency contact
Name
*
First Name
Last Name
Adult 3 Cell Phone Number
*
Adult 3 Work Phone Number
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Does Adult 3 have permission to Pick up?
*
Yes
No
Additional person to whom the children may be released:
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number when child is in care
Please enter a valid phone number.
Camper Demographics
First Name
*
Last Name
*
Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
Year
Gender
*
Please Select
Girl
Boy
Is currently Enrolled at Coventry?
*
Yes
No
Grade Entering in Fall of 2025
Please Select
Nursery
toddlers
threes
preschool
Pre-k
kindergarden
1st
2nd
3rd
4th
5th
Primarily At the Same Address as:
*
Please Select
Mother and Father
Mother only
Father only
Legal Guardian
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
T-Shirt Size
*
Please Select
Youth Small
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Allergies (including medication reaction)?
*
Please Select
Yes- Please describe below
No
Please Describe
Does your child require any of the following while at camp?
*
Epi -pen
Inhaler
Emergency Seizure Medication
Regularly Scheduled and Prescribed Medication
None
Special Disabilities (if any)
Medical or Dietary Information Necessary in an Emergency Situation
Medication, Special Situation
Please list any medications or Special situations we should know about
Health Insurance Coverage for Child or Medical Assistance Benefits
*
Policy Number
*
Medical Provider Informaton
*
Doctors Name
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Permissions
Parent's Signature is required for each item below to indicate parental consent
Obtaining Emergency Medical Care
*
Admin. of Minor First-Aid Procedures
*
Walks and Trips
*
Swimming
*
Transportation by the Facility
*
Wading
*
KI Permission Slip
By signing this form, I indicate that I have read and understand the information made available to me regarding the distribution of KI pills at Coventry Christian Schools.
Type a question
*
Yes- I DO want my child to be given potassium iodide (KI), whenInstructed by public health officials, in the event of a radioactiveemergency during school hours.
No- I DO NOT want my child to be given potassium iodide (KI), wheninstructed by public health officials, in the event of a radioactiveemergency during school hours.
Parent/ Guardian Name
*
First Name
Last Name
Signature
*
Todays Date
*
-
Month
-
Day
Year
Date
Sunscreen Permission Slip
We require our campers to apply sunscreen for those times (i.e. swimming, outdoor play) when there will be extended exposure. Ideally we would like each camper to have their own marked bottle of sunscreen to apply when it is needed. Due to allergies we need permission to use other sunscreen if for some reason your camper does not have their sunscreen with them. Without this form or without sunscreen of their own, campers will not be allowed out in the direct sun for extended periods of time.
Permission to use sunscreen
*
I grant the CCS SDC staff permission to apply the sunscreen that I will provide for my child
I grant the CCS Summer Day Camp staff permission to apply othersunscreen to my child in the event that he/she does not have their own.
I do not grant the CCS Summer Day Camp staff permission to apply othsunscreen to my child in the event that he/she does not have their own sunscreen on a day at Summer Day Camp. I understand that, without the protection of sunscreen, my child will not be allowed in the direct sunlight for extended periods of time.
Parent Name
*
First Name
Last Name
Signature
*
Date
*
-
Month
-
Day
Year
Date
Scheduling
Please indicate your intended schedule as well as start and end times below. **Please Note There is NO CAMP THE WEEK OF June 30th-July 4th **
What group would your camper be in?
*
Please Select
Nursery: 6 weeks-12 Months
Toddlers: 12 Months-2 years
Twos: 2 Years- 3 years
Threes: 3 years- 4 years
Pre-K: 4 year- 5 Years
Eaglets: entering Kindergarten- 1st
Eagles: entering 2nd-3rd
Hawks: entering 4th-5th
Start Time
*
End Time
*
Will you require Extended care?
*
Yes
No
Week 1 June 16th -20th
Please select the days attending
Nursery
Toddlers
Twos
Threes
Pre-K
Eaglet/ Hawks/ Eagles
Week 2 June 23-27th
Please select the days attending
Nursery
Toddlers
Twos
Threes
Pre-K
Eaglet/ Hawks/ Eagles
There is no camp June 30th-July 4th in observance of Independence Day!
Week 3 July 7th - 11th
Please select the days attending
Nursery
Toddlers
Twos
Threes
Pre-K
Eaglet/ Hawks/ Eagles
Week 4 July 14th -18th
Please select the days attending
Nursery
Toddlers
Twos
Threes
Pre-K
Eaglet/ Hawks/ Eagles
Week 5 July 21st-25th
Please select the days attending
Nursery
Toddlers
Twos
Threes
Pre-K
Eaglet/ Hawks/ Eagles
Week 6 July 28th- Aug 1st
Please select the days attending
Nursery
Toddlers
Twos
Threes
Pre-K
Eaglet/ Hawks/ Eagles
Week 7 Aug 4th - 8th
Please select the days attending
Nursery
Toddlers
Twos
Threes
Pre-K
Eaglet/ Hawks/ Eagles
Week 8 Aug 11th - 15th
Please select the days attending
Nursery
Toddlers
Twos
Threes
Pre-K
Eaglet/ Hawks/ Eagles
Week 9 Aug 18th - 22nd
Please select the days attending
Nursery
Toddlers
Twos
Threes
Pre-K
Eaglet/ Hawks/ Eagles
Payment
How would you like to pay for registration?
*
Online
Drop off or mail to Coventry Christian Schools
My camper is currently registered at Coventry- No registration fee is needed
My Products
prev
next
( X )
New Student Summer Day Camp Registration
Registration is only for campers not currently enrolled in Coventry Christian Schools
$
50.00
My student is currently enrolled in Coventry - No payment is needed-
$
Free
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit
Submit
Should be Empty: