Clone of English Summer Camp Registration Form

English Summer Camp Registration
Information
Which camp are you registering for?
Only 1 camp registration is possible per child per family
Child's Name

First NameLast Name
Birth Date

MonthDayYear
Age
Gender
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Which resident permit status does the child have?
Priority registration is given to those with Permis F,N,S,B refugié. If space allows, others will be considered.
Parent/Guardian Information
Name

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Does the child have any allergies, dietary restrictions, chronic illness, or medical conditions? If yes, please describe.
Does the child take any prescribed medications? If yes, please explain any instructions and provide the necessary quantity for the camp.
Informed Consent and Acknowledgement

I hereby authoze my child to attend Summer English Camp offered by the Refugee Welcome Center, an initiative of Emmanuel Episcopal Church of Geneva. The camps will take place from July 27-31 and August 3-7 (9.00-13.00) at Emmanuel Church’s premises at 3 rue de Monthoux, 1201 Geneva. The purpose of this camp is to fully immerse the children in the English language through several activities taking place throughout the week such as games, music and art led by a team of volunteers. Emmanuel Church respects the diverse backgrounds of all camp participants and ensures that its activities are secular in nature. The camp is being offered free of charge and will include the provision of lunch and a snack. By registering my child, I commit to him/her attending the entire week of camp. In the event of illness, I will contact the camp organizers in a timely manner. I understand that failure to attend the camp without justified cause may result in the exclusion from future activities offered.
Is there any personal information of which the organizers need to be aware?
Medical Release and Authorization

In the event of illness, injury or other emergency, I understand that every effort will be made to contact me. If time is of the essence, or if I cannot be reached, I hereby give the volunteers permission to act on my behalf to secure medical treatment as necessary, including, but not limited to: medical attentions, anesthesia, surgery and hospitalization, as the attending nurse or physician may prescribe. I understand that it is my responsibility to pay for any medical services which my child may receive while attending this event. I absolve and hold harmless the Fondation de la Chapelle d’Emmanuel and its designated volunteers and representatives from any liability in acting on my behalf in this regard.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Medical Insurance Information
Medical insurance company
Policy Number
Name of physician
Contact information during the camp

In case of absence of the child or any concerns during the camp, please contact the camp leader Christine Aghazarm, 076 3956827, refugees@emmanuelchurch.ch
Data protection

This information is being collected solely for the purposes of the English Summer Camp and will not be retained after that time.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

DayMonthYear
Date
Signature
Which resident permit status does the child have?
If other, please indicate here
Should be Empty:

English Summer Camp Registration

Information

Medical Insurance Information

Contact information during the camp

Data protection