St. John's Day Camp Registration, Health and Permission Form 2025

St. John's Day Camp Registration, Health and Permission Form

Dates of Camp: June 23 - June 27, 2025

Camper Name

First NameLast Name

Street Address (or P.O. Box)

City

State

Zip

Gender

Grade Completed

Birthdate

Date

T-Shirt Size:

YS YM YL AS AM AL

Home Church

City

Parent/Guardian Information

First & Last Name

Home Phone Number

Cell Phone Number

E-Mail

example@example.com

Additional Emergency Contact Information

Name

Relationship

Phone/cell

How will your child arrive & leave the day camp site? (ie: walk, car, bike, combo of all three...)

The following person(s) is/are permitted to pick up my child from Day Camp

2.

DO NOT release my child to the following person(s):

1

2.

Note any activities to be limited:

List any disabilities or recurring illnesses we should be aware of:

Specify any dietary concerns or limitations:

Note all allergies (this includes bee stings, peanuts, aspirin, penicillin, etc. Please let us know of them all):

Include current medication or medical treatment

Name and Dosage

Note: All medications sent to camp must be in the original containers and given to the Church Coordinator.

Please provide any other information or restrictions that might help the day camp staff and volunteers to know how best to care for your child (behavioral, physical, emotional, mental health):

Release: I hereby give permission for the camper, previously named, to participate in all day camp activities except as previously noted. I also consent to the use of any photograph or video recordings of my child or family in St. John's social media and printed publications.

I understand that every effort will be made to contact me if my child needs emergency medical treatment. I further authorize the adult coordinator(s), or their adult designee, to administer over the counter drugs and medications as needed.

Date

Printed Name

Parent/Guardian Signature