Spirit Camp Registration

Parent(s) Name:

E-mail (for Spirit Camp purposes only:)

Home address:

City: State: Zip:

Home phone: Work phone: Cell phone:

Home Church:

This information must be completed

Individualized special notes:
Food Allergies -- Snacks will be provided every day. If your child has a food allergy, please talk with the Spirit Camp director before camp and provide snacks from home, for your child’s safety. We will make every effort to prevent exposure to food allergens, but will not be able to guarantee it.
Food Allergies:

Other Allergies (bee stings, medications, etc):

Other medical information:

Special needs:

Emergency Information
In the event of an emergency, the Spirit Camp staff will first try to contact the parents at the phone numbers listed on this form. Please list an alternate contact person, in case the parents cannot be reached.
Contact in case of emergency: 9:00-2:00 Phone:
In the event I cannot be reached in an emergency, I hereby give permission to the staff of Spirit Camp to provide necessary treatment for the child(ren) named above.

Our physician is: Phone:

Daily Pick-up
For your child’s safety, please list the name(s) of the adult(s) – including parents - who will be picking your child up each day in the designated area. If someone else picks up your child and is not listed, please contact a Spirit Camp coordinator at the time of pick-up.

1. Name: Relationship:

2. Name: Relationship:

Privacy
Photos will be taken at Spirit Camp. One photo of each child will be used for a take-home craft project. Others may be displayed inside the building (slide show or bulletin board) or on the church website, always without names.
You may use my child’s photo inside the building. Do not use my child’s photo inside the building.

You may post my child’s photo on the website. Do not post my child’s photo on the website.

By checking this box I agree that it is an acceptable substitute for my signature. I agree that I am signing to attest that the above information is correct.

Location:	Faith Lutheran Church 2200 S. High St. - 332-1668
Dates:	Monday - Tursday, July 23-26, 2012
Classes:	Age 3 - entering Kindergarten: 9:00 am - 11:30 am Grades 1-6: 9:00 am - 2:00 pm (bring a sack lunch)
Cost:	full day: $25/child half day: $20/child
	Early Registration Deadline: Sunday, June 3 (discount of $5/child)

First Child	Second Child	Third Child
Name:	Name:	Name:
Nickname:	Nickname:	Nickname:
Birth date:	Birth date:	Birth date:
Entering grade: Pre (3) Pre (4/5) Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade	Entering grade: Pre (3) Pre (4/5) Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade	Entering grade: Pre (3) Pre (4/5) Kindergarten 1st grade 2nd grade 3rd grade 4th grade 5th grade 6th grade
Boy Girl	Boy Girl	Boy Girl
T-shirt Size: Youth S (6-8) Youth M (10-12) Youth L (14-16) Adult S Adult M	T-shirt Size: Youth S (6-8) Youth M (10-12) Youth L (14-16) Adult S Adult M	T-shirt Size: Youth S (6-8) Youth M (10-12) Youth L (14-16) Adult S Adult M
Fee: $25 $20 $15	Fee: $25 $20 $15	Fee: $25 $20 $15

Faith Lutheran Church