LWCS Summer Camp 2014 REGISTRATION FORM

LWCS Summer Camp 2014
REGISTRATION FORM
Submit one form per participant. $30 non-refundable registration fee per student is required at time of
registration. Registration fee includes LWCS Camp t-shirt.
I. General Information
Name (Last, First, MI)
___________________________________________________________________________________
Address (Street, City, State, Zip)
___________________________________________________________________________________
Birth date __________________ Age _________ School _____________________________________
Grade in Fall _________________ □ Female □ Male
Custodial Parent/Guardian Information
Registrant is in the custody of: □ Both Parents □ Mother Only □ Father Only Other: ________________
Mother/Guardian Name __________________________________________________________________
Home Phone ___________________ Cell Phone ______________________ email ___________________
Father/Guardian Name ___________________________________________________________________
Home Phone ____________________Cell Phone _____________________ email ___________________
II. Medical Information
Allergies: (Please write "none" if no allergies) ________________________________________________
Medications: List below, with doses and times
(Please write "none" if child does not take any medication.)
______________________________________________________________________________________
______________________________________________________________________________________
Medical Conditions: (Please write "none" if no medical conditions exist)
______________________________________________________________________________________
______________________________________________________________________________________
Physician name and number_______________________________________________________________
Insurance name and policy________________________________________________________________
Emergency Contact (other than Parent/Guardian) ______________________________________________
Relationship __________________________________________
Home Phone ___________________________ Cell Phone ______________________________
2013-2014 Health Examination Form on File with Living Word
□ Yes □ No
OPERATING HOURS/LATE FEES
LWCS Summer Camp will run from 7:30 a.m. to 3:30 p.m. Monday through Friday. After Care is available
from 3:30 to 6:00 at the cost of $7 per day per child. Children may not be dropped off before 7:30a.m.
Children must be picked up by 6:00 p.m. Late fees will be assessed as follows for any late pickups:
$5 for the first fifteen (15) minutes beginning at 6:01p.m., $1 per minute beginning @ 6:16p.m.
INITIALS ________
PAYMENTS/FEES
FEES ARE TO BE PAID IN FULL ON MONDAY MORNING OF EACH WEEK. Fees will be
assessed based upon the dates indicated below. Make checks payable to Living Word Christian School.
You may also make payments through Renweb. Camp fee will be $100/week or $25/day per child.
There is an additional cost for field trips.
INITIALS ________
ATTENDANCE/CANCELLATION POLICY
Any changes to camp attendance dates (including transferring days or absences) must be given with two
weeks’ prior notice. We are not able to give refunds or cancel fees for missed days of camp with less than
two weeks’ notice. If your child is unable to attend camp due to medical reasons, you may receive a full
refund by providing a doctor’s note. Days may be added with one week’s notice.
INITIALS ________
Please circle the weeks and days your child will be attending:
May 19 - 23
M
May 26 - 30
T
W Th
F
After Care: Y N
T
W Th
F
After Care: Y N
June 2 - 6
M
T
W Th
F
After Care: Y N
June 9 - 13
M
T
W Th
F
After Care: Y N
June 16 - 20
M
T
W Th
F
After Care: Y N
June 23 - 27
M
T
W Th
F
After Care: Y N
June 30 – July 4
M
T
W Th
July 7 – 11
M
T
W Th
F
After Care: Y N
July 14 – 18
M
T
W Th
F
After Care: Y N
July 21 – 25
M
T
W Th
F
After Care: Y N
July 28 – August 1
M
T
W Th
F
After Care: Y N
After Care: Y N
T Shirt Size (Circle One): Child: S M L XL Adult: S M L XL XXL
ACTIVITY RELEASE
I consent for any of my children listed below to participate in any activity or trip sponsored by
Living Word Christian Schools Summer Camp. In case of medical need, I authorize Living
Word Christian Schools Summer Camp to arrange for medical or dental services for me and any
of my children listed below. I agree that any such expense will be my obligation.
I, individually, and in my capacities as parent or guardian: _________________________
waive, release, and indemnify Living Word Christian Schools Summer Camp and its agents,
directors, employees, and volunteers (collectively, the “Released Parties”) from all claims or
liability which have arisen or may arise from any Living Word Christian Schools Summer
Camp activity or trip and which involves any damage, loss, or injury to me, my spouse, any of
my children, my property, or the property of any of my children. In the same capacities, I
promise not to sue any of the Released Parties for any such claims or liability. This waiver,
release, indemnification, and promise not to sue, does not apply to claims of criminal conduct or
gross negligence.
This Activity Release is revocable prospectively only by a writing signed by me which bears
the date that the revocation is delivered to Living Word Christian Schools.
__________________________________________
Signature
__________________________
Date
__________________________________________
Signature
__________________________
Date
Children:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
PHOTO RELEASE
I understand that when participating in Living Word Summer Camp activities the registrant may
be photographed for print, video or electronic imaging. I understand that the images may be
used in promotional and fundraising materials, news releases and other published formats, and
will be the sole property of Living Word Christian Schools.
Check if registrant MAY NOT: □ Be photographed for Living Word publicity purposes
_______________________________________________
__________________________
Signature of Parent/Guardian
Date
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