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Day Camp 2008 is July 7-11. 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 “Just For Life” with Amos 5:24 as the Bible verse for the week.
SUMMER DAY CAMP REGISTRATION
camp date: July 7-11, 2008
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 9th
______________________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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