The Final Countdown Camp

Pritchard Recreation: Sports Camp!
The Final Countdown to the school year is on! Come celebrate the ending of summer with us here at Pritchard Recreation with our final summer camp of the year. Sports, team building exercises, projects, and special prizes, let's end the summer on a high note!

Camp Details

- This camp is for kids ages 7-11.The camp is located at Pritchard Church: 1117 South Blvd. Charlotte, NC 28203

- The camp is August 14 - August 17 from 9:00-4:00.

- Drop off time is no earlier than 8:30 am and kids must be picked up by 4:30 PM.

- Kids must bring their own packed lunch.

- The price is $150 for the week.

For any questions, please contact Recreation Director: Adam Calderone acalderone@pritchardchurch.com
CHILD INFORMATION:
Child Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Name of School*
PARENT/GUARDIAN INFORMATION:
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*

Area CodePhone Number
E-mail*
example@example.com

Authorized Pick Up

List all individuals who are authorized to pick up the participant from the program; please add yourself as an authorized pick up.
Authorized Pick Up 1
Name*
Relationship*
Phone Number*

Area CodePhone Number
Authorized Pick Up 2
Name
Relationship
Phone Number

Area CodePhone Number
Authorized Pick Up 3
Name
Relationship
Phone Number

Area CodePhone Number

MEDICAL INFORMATION
Physician Name*

First NameLast Name
Name of Practice*
Phone Number*

Area CodePhone Number
Insurance Information:
Medical Insurance Company *
Phone*
Policy/Group ID #*
Medication

List all medications the participant will take during the afterschool program. Any participant under the age of 18 is required to give ALL MEDICATIONS to the adult youth leader in their original containers with complete dispensing instructions before the start of the event. Youth are not permitted to carry any prescription or non-prescription medication and will be sent home at the parent/guardian’s expense if they do.
List Medications and dosage
Medical Conditions
List any medication conditions the student has (asthma, diabetes etc)
List any allergies
Please explain any other pertinent information about the participant that would be important to know

Parental Consent
The undersigned does hereby give permission for my child/youth to attend and participate in any Pritchard Memorial Baptist Church after school activities, events, and offsite retreats during the period of June 1 - August 30 2023

LIABILITY RELEASE: In consideration of Pritchard Memorial Baptist Church allowing the Participant to engage in Pritchard Recreation Programs (Activities, Events, Retreats, Trips) I, the undersigned, do hereby release, forever discharge and agree to hold harmless Pritchard Memorial Baptist Church, its pastors, directors, employees, volunteers and teachers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the Participant while involved in the children/youth activities and childcare. I, the parent, or legal guardian of this Participant, hereby grant my permission for the Participant to take part fully in all recreation related activities, including trips away from the church premises. Furthermore, I, on behalf of my minor Participant, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of said Participant, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child/youth pursuant to this authorization.

EARLY RETURN HOME POLICY: Should it be necessary for my child/youth to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.
Signature*

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Pritchard Recreation: Sports Camp!

CHILD INFORMATION:

PARENT/GUARDIAN INFORMATION:

Authorized Pick Up

Authorized Pick Up 1

Authorized Pick Up 2

Authorized Pick Up 3

MEDICAL INFORMATION

Insurance Information:

Medication

Medical Conditions

Parental Consent