Children's Ministry

Children's Summer Day Camp

Child's Full Name

Date of Birth

Year

Month

Day

Age (4-12)

Gender

Male

Female

Address

Postal Code

Parent(s)/Guardian Names:

Home Phone Number

Parent’s Cell Number

Parent's Email Address (home/work)

Health Card Number

Allergies/food restrictions or medical conditions we should be aware of

In case of an emergency, contact

Is your child bringing any medication?

Yes

If yes, please list

Permission to take photos of Children to be shown in Church only?

Yes

Please list the people who have permission to pick up your child at the end of the day

Parent(s)/Guardian Signature

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Print Name

Date