Day Camp Registration Form

Grace/Good Sam Day Camp Registration Form

Who's My Neighbor Aug. 5-8, 2019
Camper's Information
Camper Name*
Nickname
Date of Birth*

MonthDayYear
Date
Age as of Camp date (Aug. 5, 2019)
Entering Grade in Fall 2019*
T-Shirt Size
NOTE - This program is prepared for children who have completed Kindergarten. However, younger children may be welcome if after discussion with the coordinator they are considered ready to participate with the older kids. Please contact the coordinator, Shelly Lundahl, at sdlundahl@comcast.net to discuss a younger child's readiness.
Home Church (if you have one)
Age

Parents' Information

Parent/Guardian 1
Parent/Guardian 1*

First NameLast Name
Relationship to Child*
E-mail*
Cell Phone*
Home Phone
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Work/School Name
Or enter N/A if not applicable
Parent's Work/School Phone
Where would you like to be reached while your child is at camp?*

Cell PhoneWork PhoneHome Phone
Parent/Guardian 2
Parent/Guardian 2

First NameLast Name
Relationship to Child
E-mail
Cell Phone
Home Phone
Home Address Same as Parent/Guardian 1?

Yes
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent's Work/School Name
Or enter N/A if not applicable
Parent's Work/School Phone
Where would parent/guardian 2 like to be reached while your child is at camp?

Cell PhoneWork PhoneHome Phone

Emergency Contacts/Authorized Pickup

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you.
In case of emergency, please notify:

Emergency Contact #1
Full Name*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number*
Relationship to Child*
Transportation-Approved Drivers

list anyone authorized to pick up camper
Additional Driver#1 Full Name

First NameLast Name
Driver's Phone Number
Relationship to Child
Additional Driver#2 Full Name

First NameLast Name
Driver2's Phone Number
Relationship to Child
Driver 3 Full Name

First NameLast Name
Additional Driver#3 Phone Number
Relationship to Child
Driver 4 Full Name

First NameLast Name
Driver 4's Phone Number
Relationship to Child
Does your child have permission to walk or bike home after camp?*

YesNo

Permissions
I hereby give informed and expressed consent for my child to take part in all camp activities under supervision, and agree that the Day Camp or Day Camp personnel will not be held responsible for accidents arising there. I authorize the Day Camp Healthcare Provider and/or designated Day Camp staff/volunteer to provide appropriate treatment to my child for injuries and/or illness. I understand that the information on this form may be released to the appropriate medical personnel in case of medical emergency. I also understand the failure to disclose medical or emotional problems in advance may lead to serious consequences while at Day Camp. Lastly, I verify that everything contained on this form is complete and accurate, to the best of my knowledge.*
Type first and last name above to consent
I also consent to the use of any photograph of my child or family in future Grace Lutheran or Good Samaritan publications.*
Type first and last name above to consent
Field Trip Permission: My child has my permission to participate in Day Camp activities away from Grace Lutheran Church. I am aware that campers may walk to Good Samaritan Episcopal Church or Chintimini Park Monday, Wednesday, or Thursday (8/5-8) and go to Hesthaven in Corvallis (Oak Creek Rd. area) by bus on Tuesday (8/6). The camper has permission to ride/walk to the field trip destinations under the supervision of the Day Camp Volunteers.*
Type first and last name above to consent
Sign Document*
Date Signed*

MonthDayYear
Camp Director Name and Contact Info
Payment
Thank you for registering your child for Day Camp!

Suggested registration is $25/camper and $20/+child in a family.

We want this experience to be available to all families regardless of circumstances. If your child needs a campership to attend, please enter the amount you can contribute and complete the card information to Submit the form.
How would you like to contribute to registration?

Pay with debit/credit card - Information submitted belowPay with check - bring/send to Grace Lutheran ChurchOther

Registration Contribution

USDRegistration cost is $25/camper. If you would like a campership for your child, please enter the amount you are able to contribute and indicate you would like to contact the Coordinator.

Credit/Debit Card Information

Please check box if you would like to discuss a campership

Yes, I would like a campership
Should be Empty:

	Mild	Moderate (Swelling or severe rash)	Severe (Difficulty Breathing)
Food
Medication
Environmental (animal, plant, insect, etc…)
Other

Grace/Good Sam Day Camp Registration Form

Camper's Information

Parents' Information

Emergency Contacts/Authorized Pickup

In case of emergency, please notify:

Transportation-Approved Drivers

Medical / Health Information

Additional Medication

Permissions

Payment

Credit/Debit Card Information