Only One Child Per Form Please Print

ONLY ONE CHILD PER FORM—PLEASE PRINT

______

Campers Legal Last Name First Name Preferred Name/Nickname

______Gender: (please circle) Male Female

Address City State Zip

Date of Birth: ______Age: _____ Fall 2017 Grade: _____ School Attending: ______

Information for: (please circle) Father Mother Step parent Grandparent Guardian

Full Name: ______Email: ______

Address (if different from above): ______

Home Phone: ______Cell Phone: ______Work Phone: ______

Information for: (please circle) Father Mother Step parent Grandparent Guardian

Full Name: ______Email: ______

Address (if different from above): ______

Home Phone: ______Cell Phone: ______Work Phone: ______

Information for: Emergency Contact

Full Name: ______Relationship to Camper: ______

Address (if different from above): ______

Home Phone: ______Cell Phone: ______Work Phone: ______

Medical Release: If emergency treatment is required for my child and a parent or legal guardian can’t be reached, I hereby authorize treatment for my child, should the attending physician deem it necessary. ______

Signature of parent/guardian

Photo Release: I hereby consent to and authorize the use and reproduction by Ascension Lutheran Church of any and all images of my child captured with video, photo, or digital camera, to be used for publications of print/video/webpage. ______

Signature of parent/guardian

Rules and regulations: I have read and understand all the rules of the Summer at the Rock.______

Signature of parent/guardian

CHECK ALL THAT APPLY FOR THIS CHILD AND INDICATE THE TOTAL EACH WEEK

CAMP DATE / THEME / Weekly
Fee / BEFORE CARE
$5/day / AFTER CARE
$10/day / Lunch
Orders
$5/meal / Weekly TOTAL
Week 1
June 5-9 / Exploration Week / ___$105 / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / $
Week 2
June 12-16 / Superhero Week / ___$105 / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / $
Week 3
June 19-23 / Star Wars Week / ___$105 / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / $
Week 4
June 26-30 / Hawaiian Week / ___$105 / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / $
Week 5
July 3-7 / Ascension’s Got Talent / ___$105 / M__ T__ W__
Th__ F__ Total: $___ / M__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / $
Week 6
July 10-14 / Sports
Week / ___$105 / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / $
Week 7
July 17-21 / Christmas in July / ___$105 / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / $
Week 8
July 24-28 / Police and
Fire Week / ___$105 / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / M__ T__ W__
Th__ F__ Total: $___ / $
Week 9
July 31-Aug 3 / Throwback / ___$105 / M__ T__ W__
Th__ Total: $___ / M__ T__ W__
Th__ Total: $___ / M__ T__ W__
Th__ Total: $___ / $