Day Camp 2017
Countryside Christian Church
Day Camp 2017 June 5 – June 7 God is Real. The Bible is True. Jesus is Alive! First Name:__________________________________ Last Name:___________________________________ Preferred Name for Nametag:__________________________________ Address:_______________________________ City:__________________ State:_______ Zip:___________ Primary Phone:____________________________ Email:___________________________________________ Grade Entering Fall 2017:_______________ T-shirt Size:_______________ T-shirt Sizes are YXS (2-4), YS (6-8), YM (10-12), YL (14-16), YXL (18-20), AS, AM, AL, AXL Male______ Female______ Age (during camp)_______ Date of Birth (MM/DD/YYYY) __________________ Parent/Guardian____________________________________ Cell Phone_____________________________ Alternate Emergency Contact__________________________ Cell Phone_____________________________ How did you hear about camp? __________________________________________ Allergies:____________________________ Medications(daily or emergency):____________________________ Known Health or Behavioral Concerns:__________________________________________________________ Transportation Countryside Christian Church will provide transportation to day camp from any area school. Parents are responsible for picking up their children from Countryside at the end of day camp each day.
Need Transportation? No______ From (circle one)
Brashear School
Yes______ (if yes, circle days needed) Monday Tuesday Wednesday Kirksville Primary
La Plata School Novinger School
Ray Miller
Pick-up is at 5pm @ Countryside. To whom may we release your child: __________________________________________________________________________________________ I request the above mentioned child attend Day Camp 2017 (June 5th – June 7th) at Countryside Christian Church. I agree to having Day Camp staff members secure any emergency medical care or treatment that may be necessary for my child during the entire camp, including transportation to Day Camp as noted above. I further assume all responsibility for the decision so made and the emergency care secured for my child. I do waive, release, absolve, indemnify and agree to hold harmless Countryside Christian Church, the organizers, sponsors, supervisors, participants and persons transporting my child to the camp, for any claim arising out of an injury to my child, whether the result of negligence or any other cause. I agree that pictures and images of my children may be used by Countryside Christian Church.
Parent/Guardian Signature________________________________________ Date_________________
Day Camp 2017 June 5 – June 7 God is Real. The Bible is True. Jesus is Alive! First Name:__________________________________ Last Name:___________________________________ Preferred Name for Nametag:__________________________________ Address:_______________________________ City:__________________ State:_______ Zip:___________ Primary Phone:____________________________ Email:___________________________________________ Grade Entering Fall 2017:_______________ T-shirt Size:_______________ T-shirt Sizes are YXS (2-4), YS (6-8), YM (10-12), YL (14-16), YXL (18-20), AS, AM, AL, AXL Male______ Female______ Age (during camp)_______ Date of Birth (MM/DD/YYYY) __________________ Parent/Guardian____________________________________ Cell Phone_____________________________ Alternate Emergency Contact__________________________ Cell Phone_____________________________ How did you hear about camp? __________________________________________ Allergies:____________________________ Medications(daily or emergency):____________________________ Known Health or Behavioral Concerns:__________________________________________________________ Transportation Countryside Christian Church will provide transportation to day camp from any area school. Parents are responsible for picking up their children from Countryside at the end of day camp each day.
Need Transportation? No______ From (circle one)
Brashear School
Yes______ (if yes, circle days needed) Monday Tuesday Wednesday Kirksville Primary
La Plata School Novinger School
Ray Miller
Pick-up is at 5pm @ Countryside. To whom may we release your child: __________________________________________________________________________________________ I request the above mentioned child attend Day Camp 2017 (June 5th – June 7th) at Countryside Christian Church. I agree to having Day Camp staff members secure any emergency medical care or treatment that may be necessary for my child during the entire camp, including transportation to Day Camp as noted above. I further assume all responsibility for the decision so made and the emergency care secured for my child. I do waive, release, absolve, indemnify and agree to hold harmless Countryside Christian Church, the organizers, sponsors, supervisors, participants and persons transporting my child to the camp, for any claim arising out of an injury to my child, whether the result of negligence or any other cause. I agree that pictures and images of my children may be used by Countryside Christian Church.
Parent/Guardian Signature________________________________________ Date_________________
