2015 KID2KID Camp Registration Form

 


Participant Name: *
First Name
Middle
Last Name
Choose Grade as of Fall 2015: *
If only registering ONE kid, SKIP to Parent/Guardian Name(s).
If registering MORE than ONE kid, continue filling out the participant info for each kid.
Participant Name:
First Name
Middle
Last Name
Choose Grade as of Fall 2015:
Participant Name:
First Name
Middle
Last Name
Choose Grade as of Fall 2015:
Participant Name:
First Name
Middle
Last Name
Choose Grade as of Fall 2015:
Parent or Guardian Name(s): *
First Name
Middle
Last Name
First Name
Middle
Last Name
Home Address: *
Address Line 1
Address Line 2
City
State/Prov.
Postal Code
Phone Number:*
Email:*
Family Physician:
First Name
Middle
Last Name
Physician Phone Number:
Is the participant covered by medical insurance?*
Insurance Company Name:
Insurance Policy Number:
Emergency Contact (If parent cannot be reached): *
First Name
Middle
Last Name
Emergency Contact Phone Number:*
Emergency Contact's Relationship to Participant:*
Medical Alert Information: Please list known allergies, current prescriptions, and/or other medical conditions):
Please choose any combination of camp dates (all, only one, or sporadic): *
We (I) the parent(s) or legal guardian(s) of this participant hereby grant our (my) permission for him/her to participate fully in said activity and hereby give our (my) permission to St. John Mennonite Church to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation, to emergency surgery or medical treatment, and assume the responsibility of all medical bill, if any.
Please Check One: *
Are you interested in volunteering?
I release all images of my children produced by the St. John Mennonite staff and their volunteers for communicative and promotional purposed including, but not limited to flyers, videos, and the St. John Mennonite website.*
Thank you for registering for Kid2Kid Camp 2015! Remember, each participant needs to be registered individually. You should receive a reply within 3 days via email.