The Salvation Army Day Camp Registration
The Salvation Army
Date Rcvd: ___________
Day Camp Registration 2000 Court St Port Huron, Michigan 810.984.2679
Name _______________________________________
Age ___________
Date of Birth: ____ /____ /____
Address ____________________________________ City ____________________________ Zip ___________ Gender: M F
Current Grade: _____________
School _______________________________________
Camper’s T-Shirt Size: Please check below. One shirt is provided; a 2nd shirt can be purchased for an additional cost. (Child Sizes) S□ M□ L□ (Adult Sizes) S□ M□ L□ XL□ I would like to order a 2nd shirt for an extra $10.00 □ Please mark the weeks that your child will be attending Summer Day Camp 2016: Week 1: June 20-24
Week 2: June 27-July 1
Week 6: July 25-29
Week 7: August 1-5
Week 3: July 4-8 Week 8: August 8-12
Week 4: July 11-15 Week 9: August 15-19
Week 5: July 18-22 Week 10: August 22-26
Hours: Day Camp hours are from 8:00am- 5:00pm. Please indicate below the times of care you may need for your child. (Please be specific with times that care is needed, so that we can staff accordingly. Thank you!)
Drop off time: _____________
Pick up time: ______________
Father / Male Guardian______________________________________ Home Phone: ___________________________ Cell Phone:_______________ Work Phone _______________ Email Address: ___________________________________ You may text this phone number regarding Day Camp Reminders
Mother / Female Guardian __________________________________ Home Phone: ___________________________ Cell Phone: _______________ Work Phone _______________ Email Address: __________________________________ You may text this phone number regarding Day Camp Reminders
In case of an emergency, please call this number first: ____________________________________________________
SWIMMING ABILITY of Child on this Registration Form …………. (Check only one)
□Non-swimmer □ Beginner (capable of swimming for several minutes) □Moderate (capable of swimming several pool lengths and in deep water) □Advanced Does he or she have your permission to swim? Yes□ No □ Additional Notes: _____________________________________ Does he or she need to wear a life jacket (provided from home) on swimming days? Yes□ No □
Medical Information
[Please fill out COMPLETELY providing all current information.]
Medical Insurance Carrier & Number _________________________________________________________________________ List any recent illnesses / or medical problems we should be aware of: _______________________________________________________________________________________________________ List any allergies that your child has (include medication allergies): _______________________________________________________________________________________________________ Is your child on any medications currently? ___________ If yes, what type? __________________________________________
Emergency Contacts Any medication that will need to be given by day camp staff will require an additional form to be filled out
In the event of an emergency and a parent/guardian cannot be contacted, please list any other emergency contact that you would and in before medication be given. includes over-the-counter ask usturned to contact. My child may bewill released onlyThis to his/her legal guardians or medications. the following Emergency Contacts:
_______________________________ Name
_____________________ Relationship
________________ Home Phone
___________________ Work Phone
_______________________________ _____________________ Name Relationship
________________ Home Phone
___________________ Work Phone
Name and Phone Number of your child’s doctor: ___________________________________________________
Do you have a Church you currently attend?
Yes□ No□ Are you interested in more information about The Salvation Army as a church? Yes, please! □
How did you hear about Day Camp?
No, thanks.□
Flyer□ E-mail□ Word of Mouth□ Returning□ Other: _______________
Consent and Release Information: My signature below acknowledges agreement to the following:
Activity Release: The above named child has my permission to attend the Summer Day Camp at The Salvation Army Port Huron. He/she is free to participate in all the activities listed in the Day Camp Handbook as well as the off-site field trips. It is agreed that I do not hold The Salvation Army responsible for negligence on the part of my child during any aspect of this program. Photo Release: In the event that The Salvation Army would wish to use a photo of my child in its publicity, my permission is granted. This includes both print and electronic media. Health Release: In the event that a parent or emergency contact cannot be reached, The Salvation Army’s Day Camp Leaders have my permission to secure emergency medical and / or surgical treatment for the above named child. Registration Fees & Deposits: Registration forms must have a non-refundable $35 registration fee, along with a payment covering two weeks of care. The remainder of the fee is due according to the fee schedule. There are NO REFUNDS after Day Camp begins.
In signing below, I agree that all of the information I have given is accurate. False information will result in the termination of my child’s membership in the program. If any changes in the information provided should occur, I will immediately notify the Community Center Office.
Parent’s Signature ________________________________ Date: _______ [Must be signed for admission].
Date Rcvd: ___________
Day Camp Registration 2000 Court St Port Huron, Michigan 810.984.2679
Name _______________________________________
Age ___________
Date of Birth: ____ /____ /____
Address ____________________________________ City ____________________________ Zip ___________ Gender: M F
Current Grade: _____________
School _______________________________________
Camper’s T-Shirt Size: Please check below. One shirt is provided; a 2nd shirt can be purchased for an additional cost. (Child Sizes) S□ M□ L□ (Adult Sizes) S□ M□ L□ XL□ I would like to order a 2nd shirt for an extra $10.00 □ Please mark the weeks that your child will be attending Summer Day Camp 2016: Week 1: June 20-24
Week 2: June 27-July 1
Week 6: July 25-29
Week 7: August 1-5
Week 3: July 4-8 Week 8: August 8-12
Week 4: July 11-15 Week 9: August 15-19
Week 5: July 18-22 Week 10: August 22-26
Hours: Day Camp hours are from 8:00am- 5:00pm. Please indicate below the times of care you may need for your child. (Please be specific with times that care is needed, so that we can staff accordingly. Thank you!)
Drop off time: _____________
Pick up time: ______________
Father / Male Guardian______________________________________ Home Phone: ___________________________ Cell Phone:_______________ Work Phone _______________ Email Address: ___________________________________ You may text this phone number regarding Day Camp Reminders
Mother / Female Guardian __________________________________ Home Phone: ___________________________ Cell Phone: _______________ Work Phone _______________ Email Address: __________________________________ You may text this phone number regarding Day Camp Reminders
In case of an emergency, please call this number first: ____________________________________________________
SWIMMING ABILITY of Child on this Registration Form …………. (Check only one)
□Non-swimmer □ Beginner (capable of swimming for several minutes) □Moderate (capable of swimming several pool lengths and in deep water) □Advanced Does he or she have your permission to swim? Yes□ No □ Additional Notes: _____________________________________ Does he or she need to wear a life jacket (provided from home) on swimming days? Yes□ No □
Medical Information
[Please fill out COMPLETELY providing all current information.]
Medical Insurance Carrier & Number _________________________________________________________________________ List any recent illnesses / or medical problems we should be aware of: _______________________________________________________________________________________________________ List any allergies that your child has (include medication allergies): _______________________________________________________________________________________________________ Is your child on any medications currently? ___________ If yes, what type? __________________________________________
Emergency Contacts Any medication that will need to be given by day camp staff will require an additional form to be filled out
In the event of an emergency and a parent/guardian cannot be contacted, please list any other emergency contact that you would and in before medication be given. includes over-the-counter ask usturned to contact. My child may bewill released onlyThis to his/her legal guardians or medications. the following Emergency Contacts:
_______________________________ Name
_____________________ Relationship
________________ Home Phone
___________________ Work Phone
_______________________________ _____________________ Name Relationship
________________ Home Phone
___________________ Work Phone
Name and Phone Number of your child’s doctor: ___________________________________________________
Do you have a Church you currently attend?
Yes□ No□ Are you interested in more information about The Salvation Army as a church? Yes, please! □
How did you hear about Day Camp?
No, thanks.□
Flyer□ E-mail□ Word of Mouth□ Returning□ Other: _______________
Consent and Release Information: My signature below acknowledges agreement to the following:
Activity Release: The above named child has my permission to attend the Summer Day Camp at The Salvation Army Port Huron. He/she is free to participate in all the activities listed in the Day Camp Handbook as well as the off-site field trips. It is agreed that I do not hold The Salvation Army responsible for negligence on the part of my child during any aspect of this program. Photo Release: In the event that The Salvation Army would wish to use a photo of my child in its publicity, my permission is granted. This includes both print and electronic media. Health Release: In the event that a parent or emergency contact cannot be reached, The Salvation Army’s Day Camp Leaders have my permission to secure emergency medical and / or surgical treatment for the above named child. Registration Fees & Deposits: Registration forms must have a non-refundable $35 registration fee, along with a payment covering two weeks of care. The remainder of the fee is due according to the fee schedule. There are NO REFUNDS after Day Camp begins.
In signing below, I agree that all of the information I have given is accurate. False information will result in the termination of my child’s membership in the program. If any changes in the information provided should occur, I will immediately notify the Community Center Office.
Parent’s Signature ________________________________ Date: _______ [Must be signed for admission].
