Day Camp Camper Registration Application

CROS CAMPS

Day Camp Camper Registration Application

CROS CAMPS will be offering three six-week day camps in Lake Worth, Delray Beach, and Belle Glade. The camps will be held June 15 - July 24, 2009. The camps are for children in K-5th grades. The children must have completed kindergarten by May 2009.

The Children will enjoy bible study, arts & crafts, music, outdoor games, speakers and a whole variety of other summer activities in a caring and Christian environment. The camp is Christian oriented, but non-denominational.

CROS CAMPS day camp program is directed and supervised by Christians Reaching Out to Society, Inc. (C.R.O.S. Ministries); an ecumenical, interfaith ministry serving Palm Beach County.

There is a $25 per camper registration fee.

The Day Camps will be held in:

Delray Beach
St. Matthew’s Episcopal Church
404 S.W. 3rd St.
Monday – Friday
8:30 AM – 5 PM
Child care provided until 6pm at
a cost of $7 per child per day. / Lake Worth
Calvary United Methodist Church
301 1st Ave. South
Monday – Friday
8 AM – 5PM
Child care provided until 6pm at
a cost of $7 per child per day.
Belle Glade
Community United Methodist Church
401 S.W. 1st St.
Monday - Friday
8AM – 2PM /

Fill out the enclosed application form, have it notarized, and mail back with a copy of your child’s birth certificate or school report card and a copy of last year’s (2008) tax return. Only one camper per application; include the $25 registration fee with the application.

Spaces are limited. Children are accepted on a first come first serve basis.

Failure to provide ALL required documentation, failure to notarize the application, and/or failure to submit the registration fee will result in a delay

of your child’s camp registration process.

For all questions call 561-233-9009 ext. 103 or email .

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CROS CAMPS

A Program of Christians Reaching Out to Society, Inc.

Day Camp Camper Registration Application

Complete this form and return it with a copy of the camper’s birth certificate or school report card and a copy of your tax return for the year 2008. This application must be notarized. Failure to provide required documentation, failure to notarize this application and failure to submit the registration fee will result in a delay in your child’s camp registration process. . There is a $25 registration fee per application.

I. Camper’s Personal Data

No more than one child per application. If you need additional applications you may make a copy of this application or applications are available at our website at www.crosministries.org or by calling 561-233-9009 ext. 103.

Camper’s name ______Nickname______

First Last

Sex: G Male G Female Date of Birth ______Age ______Grade in School (Fall 2009) ______

T-Shirt Size: 10-12 G 14-16 G 16-18 G Adult Small G Adult Large G

Address ______

Street City Zip

Mailing Address (if different from home address) ______

Street City Zip

II. Parent/Guardian Data

Mother’s name ______Work phone ______

First Last

Home phone ______Cell phone ______Email ______

Are we authorized to release your child the Mother? G Yes G No

Father’s name ______Work phone ______

First Last

Home phone ______Cell phone ______Email ______

Are we authorized to release your child the Father? G Yes G No

Legal guardian ______Work phone ______

First Last

Home phone ______Cell phone ______Email ______

Adult to be notified in case of an emergency (if different than parent/guardian):

Name ______Relationship to camper ______

First Last

Work phone ______Cell phone ______Home phone ______

III. Campsite Information

Your child can only attend one campsite. However, should you need to change locations, contact the camp director immediately. Please note that your child may attend all six weeks. Only mark the weeks that your child will be at camp.

Please place an X on the campsite location you wish your child to attend.

G Lake Worth G Delray Beach G Belle Glade

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Please place an X by the week(s) that you would like your child enrolled. Your child may attend all six weeks.

G Week 1, June 15-19 G Week 4, July 6-10

G Week 2, June 22-26 G Week 5, July 13-17

G Week 3, June 29 - July 2 G Week 6, July 20-24

Will your child walk home from camp? G Yes G No Will your child walk to camp? G Yes G No

Does your child need after care? G Yes G No (Please note that there is a cost of $7 per child per day.)

Will your child go home with any other person aside from you? G Yes G No

Your child will ONLY be released to the person’s listed below. We will NOT release your child to anyone NOT listed below.

1. Name ______Relationship to camper ______Phone ______

2. Name ______Relationship to camper ______Phone ______

3. Name ______Relationship to camper ______Phone ______

IV. Family Information

Will your child be attending summer school? G Yes G No G Not sure

If not sure, will you advice the camp staff if your child will attend summer school? G Yes G No

How did you find out about Day Camp? ______

Does your child attend church? G Yes G No

If yes, Church name ______

Church denomination ______Website ______

Church address ______

Street City Zip

Children’s Ministry Leader ______Phone ______Email ______

Camper’s Race: G Caucasian G Native Indian

G Asian G Haitian

G African American G Haitian American

G Hispanic G Other

G Hispanic American

V. Camper’s Health History

List any medications your child is allergic to ______

List any foods your child is allergic to ______

List any health/psychological problems currently affecting your child ______

______

List all medications your child is currently taking ______

______

Any medications brought to camp must be in its original container. The container must have the child’s name, the dosage as prescribed by the doctor, the date, and doctor’s name. We will not administer any over-the-counter medications that are brought to camp.

Camper’s Height ______Camper’s Weight ______

My child may be given Tylenol or Benadryl if deemed necessary? G Yes G No

Does camper use eyeglasses/contacts? G Yes G No

Has camper been exposed to any communicable diseases such as skin infections, impetigo, conjunctivitis (pink eye)?

G Yes G No

If yes, list ______

On the following section, check the box that applies.

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Has camper had/is camper subject to:

Yes No

Convulsions G G

Epilepsy G G

Heart trouble G G

Fainting spells G G

Asthma/wheezing G G

Frequent stomach upsets G G

Hearing problems G G

Epileptics G G

Ear infections G G

Rheumatic fever G G

Bladder/kidney trouble G G

Serious illness G G

If yes, explain serious illness: ______

Is the camper allergic to:

Yes No

Bee stings G G

Red Ants G G

Insect bites G G

Peanuts G G

Penicillin G G

Aspirin G G

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Name of child’s doctor: ______Phone ______

VI. Parent Agreement

Read the following statements carefully. The application must be signed in front of a notary. Do not sign the application prior to.

In the event that I cannot be reached, I hereby give permission for my child to receive any treatment necessary in case of emergency. The choice of doctor, hospital, medical, or other facility may be determined by the camp staff.

I will not hold Christians Reaching Out to Society, Inc. (C.RO.S. Ministries), St. Mathew’s Episcopal Church, Calvary United Methodist Church, Community United Methodist Church, or any other sponsoring or participating organization, church, or individual responsible for any injury or illness that is incurred by my child during his/her stay or travel to and from camp.

I hereby give permission for my child to be photographed, videotaped or recorded to be used by Christians Reaching Out to Society, Inc., any designee of C.R.O.S. Ministries to be used in print, website, radio, or television media, at its discretion.

In the event that misrepresentation of information is used on this form, I understand that my child will be dismissed from the camping program. Should I have any questions, I know that the camp director is available to answer any questions that I may have.

Parent/Guardian Signature ______Date ______

THIS FORM MUST BE NOTARIZED. A notary public is available at our main office (at no cost to you) or any court house, city hall, or bank.

Seal Notary Public ______

Expiration Date ______

Complete this form and return it with a copy of the camper’s birth certificate or school report card and a copy of your tax return for the year 2008. This application must be notarized. Failure to provide required documentation, failure to notarize this application and/or failure to submit the registration fee will result in a delay in your child’s camp registration process. . There is a $25 registration fee per application.

CROS CAMPS

A Program of Christians Reaching Out to Society, Inc.

301 1st Ave. South

Lake Worth, FL 33460

561-233-9009 ext. 103 ~ 561-233-9819 Fax

www.crosministries.org ~

CROS CAMPS

A program of Christians Reaching Out

to Society, Inc.

301 1st Ave South

Lake Worth, FL 33460

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