Camper's Name *

Please fill out one form per child

First Name

Last Name

Camper's Birth Date *

MM

DD

YYYY

Parent or Guardian *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian Cell Phone *

(###)

###

####

Alternative Parent/Guardian Phone Number

(###)

###

####

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Are you able to assist with volunteer duties?

Yes

No

Does your Camper have any of the following allergies *

Food

Insects

Medicine

Seasonal Allergies

Other

None

Pediatrician's Name *

First Name

Last Name

Pediatrician's Phone Number *

(###)

###

####

Dentist's Name *

First Name

Last Name

Dentist's Phone Number *

(###)

###

####

Policy Holder's Name *

First Name

Last Name

I certify that my child listed has my permission to attend Music Camp 2023 at Christ Presbyterian Church. *

Yes

No

I affirm I am the parent/guardian of the child listed above and I give my permission for the adult leaders of this activity to administer any first aid necessary in the event of an accident and until such time as medical help can be obtained (if necessary). *

Yes

No

In the event that medical help is needed, I give permission to the physician selected by the adult leaders to hospitalize, secure proper treatment for, use ambulance, and to order injection, anesthesia or surgery for my child. I understand that in the event that medical help is needed for my child, ever attempt will be made to contact me as soon as possible. *

Yes

No

I affirm I am the parent/guardian of the child listed above and I grant Christ Presbyterian Church my permission to use the photographs/videos from Music Camp, including but not limited to: publicity, copyright purposes, illustration advertising, and web content. I understand that no royalty, fee or other compensation shall become payable to me by reason of such use. *

Yes

No

My child will sign themselves out and walk home. I release Christ Presbyterian Church from any liability pertaining to my choice. *

Yes

No