Language
English (US)
Español (México)
Pleasant Green United Methodist Church
3005 Pleasant Green Road
Durham, NC 27705
www.pleasantgreenumc.org
Church phone (919) 383-5764
Director
Wendy Anderson, 919-630-1939
pleasantgreenafterschool@gmail.com
Application for Afterschool Program / Summer Day Camp
School Year
Name of Student:
First Name
Middle Initial
Last Name
Date of Birth:
-
Mes
-
Día
Año
Date Picker Icon
Gender:
T-Shirt Size:
Address:
Home Phone #:
Format: (000) 000-0000.
E-Mail Address: (print)
ejemplo@ejemplo.com
Grade in Fall:
School:
Teacher
Student will be full-time (5 days a week)
or Part-time / List days (4 or fewer days a week)
List days attending
Parents Information
Marital Status:
If separated/divorced, custodial parent:
Are parents members of a church? If so, name of church:
Name of Mother/Guardian:
Address
Home Phone #
Format: (000) 000-0000.
Where Employed
Phone #
Format: (000) 000-0000.
Cell Phone#
Format: (000) 000-0000.
Name of Father/Guardian:
Address
Home Phone #
Format: (000) 000-0000.
Where Employed
Phone #
Format: (000) 000-0000.
Cell Phone#
Format: (000) 000-0000.
Other children in home (list below)
Name
Sex M/F
Age
Name
Sex M/F
Age
Field Trip Permission
(Child's name) has my permission to go on all field trips during this Afterschool/Summer Camp session.
Parent / Guardian Signature
Date
-
Mes
-
Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
(Please fill out the back of this form)
Back
Next
Medical Emergency and Medication Authorization
I hereby grant permission to the Pleasant Green UMC Afterschool / Summer Camp Staff present during any emergency or accident involving my child
to obtain the services of a hospital. I also grant permission to the physician to treat my child unless I am present.
Child's full name
*** (mark one)*** I
GRANT
or
DO NOT GRANT
permission to the Pleasant Green Staff to administer the appropriate dose of Acetaminophen to my child should he/she need it.
Parent / Guardian signature
Date
-
Mes
-
Día
Año
2 digit month, 2 digit day, 4 digit year
Fecha
May we use your child's photo on PGUMC's website & FB/Instagram page?
YES
NO
May we apply bug spray to your child as needed when outside?
YES
NO
May we apply sunscreen to your child as needed?
YES
NO
Does your child need a life vest when swimming?
YES
NO
Child's Physician
Format: (000) 000-0000.
Physician's Phone Number
Child's Dentist
Format: (000) 000-0000.
Dentist's Phone Number
Hospital Preference
Does your child have any physical ailments or allergies of which we should be notified?
Yes
No
If yes, describe
Please list food allergies / aversions
Is your child on any medication? If so, type and for what and when? Include a need for Epipen on site.
Does he/she take medication during the school year? If so, what type?
Does your child have any challenges with large or small group activities?
Yes
No
If yes, what type?
Has he/she had other Afterschool / Summer Camp experiences? When and where?
Other than parents/guardians already provided, list names and phone numbers of persons to contact in case of emergency and authorized to pick up your child from Pleasant Green UMC without a note, text or call to the staff.
Preview PDF
Submit
Should be Empty: