St. Christopher Episcopal Church

821 Edgewood Drive, Charleston, WV 25302 (304)342-3272

Summer Day Camp

Doors open at 8:30 a.m. Pick-up: 3 p.m.
Children: Ages 6 - 12

July 13 - 17, 2015 9am- 3pm

Enrollment Form and Waiver

(Required: Complete both sides of this form)

Child’s Name: ______Age: ______Grade _____

Date of Birth: ______Sex: (circle one) F M

Fall 2015

Address: ______

Parent(s)/Guardian Name:

______

IMPORTANT: Parent(s)/Guardian(s) are responsible for administering medication. St. Christopher must be made aware of any health conditions, medications, medical procedures and emergency procedures.

Mother’s Telephone No: (Home) ______(Cell/Work) ______Email:______

Father’s Telephone No. (Home) ______(Cell/Work) ______Email:______

Allergies/ Health Conditions: ______

T -Shirt Size (Circle One): Child: XS S M L / Adult: S M L XL XXL XXXL

Pick-up: List the person(s)s that has(have) your permission to pick-up your child (I.D. Required) other than parent or guardian.

______

Signature: ______

St. Christopher Episcopal Church

821 Edgewood Drive, Charleston, WV 25302 (304) 342-3272

Summer Day Camp

Waiver of Liability Form

I, ______, give permission for my child, ______, to participate in Summer Day Camp sponsored by St. Christopher Episcopal Church. I understand that I will be made aware of all scheduled activities and field trips prior to the event for my approval. In the event of an accident, I will not hold St Christopher Episcopal Church, the Diocese or employees responsible for any accidental injuries. I have advised the sponsor of the special needs or conditions of my child and activities from which my child should be restricted. In the event of an emergency, I understand that the listed physician, parent or guardian will be notified immediately.

I agree that St. Christopher Episcopal Church may seek emergency medical attention for my child if I

cannot be reached immediately:

Physician’s Name ______Phone number______

Health Insurance______Named Insured______

ID#______Group#______Phone#______

Parent’s Emergency Phone Number (Cell) ______Other______

Signature ______Date ______

I grant permission to St. Christopher Episcopal Church to photograph my child to appear on the church web page, the church Facebook page and/or as a part of advertisement for the Summer Day Camp.

Signature______Date ______

Form date: 5/17/2015

2