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Day Camp 2009 is July 6-10. Please call 866-4324 for more information. Registration blanks are in the church office (10-noon on MWF) or print what is below. The camp is from 9-3 every day and the theme this year is “Love to Serve” with Mark 10:45 as the Bible verse for the week....”For the Son of Man came not to be served but to serve, and to give his life a ransom for many.” SUMMER DAY CAMP REGISTRATION camp date: July 6-10, 2009 Name of Camper____________________________ Birth date_____________ Gender______________ Address, City, State, Zip______________________ _______________________________________ Grade completed___ age:__Home Church________ Parent/Guardian Name(s)_____________________ Home Phones_______________________________ Work Phones_______________________________ Cell Phones________________________________ Email_____________________________________ Emergency Contact Information 1. name__________________________________ address__________________________________ 2. name__________________________________ address__________________________________
During Day Camp, how will your child come and leave from the day camp site? (circle all that apply) walk bike car The following person(s) is/are permitted to pick up my child from Day Camp: 1.______________________ 2.___________________3.___________________ 4._______________________________________
DO NOT release my child to the following person(s): 1.___________________2.___________________
Parent Permission To the best of my knowledge, this health history is correct and complete. I hereby give permission for use of photos of my child to be used in promotion. I hereby give permission for the above named child to participate in all LOMO Day Camp activities at St. Jacob Lutheran in Miamisburg. I hereby give permission for my child to be transported to an off-site activity by an adult driver including field trips and special events on or away from the church’s property as listed: Germantown Reserve Cottonwood Shelter, 6910 Boomershine Rd. Germantown, OH 855-7717 on Wednesday, July 8th ______________________parent/guardian signature date_________please print name________________
Required Health Information
Doctor’s Name______________ Dr. Phone________ Dentist’s Name_____________ Dent. Ph._________ Your Medical Insurance Carrier__________________ Group Number_______________________________ Name of Policy Holder_________________________ Policy Holder’s Number________________________ List any disability or recurring illness:____________ Note any activities to be limited_________________ Specify any dietary concerns or limitation_________ __________________________________________ Indicate current medication or medical treatment: Note: All medications sent to camp must be in the original containers and given to the Adult Coordinator Name Dosage 1.________________________________________ 2.________________________________________ 3.________________________________________ Note all allergies: Bee Stings_Aspirin_Penicillin_Peanuts_Other______
Immunization Record - Please note the dates of the following immunizations or check current_____ DTP: Tetanus/Diptheria: Tetanus: Varicella (chicken pox): MMR: Polio: MMR: Haemophius Influenza B: Hepatitis B:
Please clarify anything else that might help the Day Camp staff regarding your child, especially related to behavioral, physical, emotional, or mental health: _________________________________________
AUTHORIZATION OF TREATMENT In the event I cannot be reached, I give permission for the staff of this Day Camp to order X-rays, routine tests and medical treatment for my child until I can be present or involved in the care. I give permission for camp staff to administer medication as listed further on this form
________________________ _____ _______________________ parent/guardian signature date please print name St. Jacob Lutheran Church on 213 E. Central Ave. Miamisburg, Ohio 45342 866-4324 www.stjacob.net
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