Event Registration

Vacation Bible School Registration

I would like to register my child for Splash! Summer Day Camp sponsored by Good Shepherd Lutheran Church, July 8-12, 2019.

Parent/Guardian Name

Mailing Address

Email address

Phone Numbers (cell, home, work)

What is the best way to contact you?

Cell phone

Home phone

Work phone

Emergency Contact Name and Phone Number

Health care provider name and phone number

Name of Child 1

Birthday and Grade completed for Child 1

Allergies, health concerns, or other helpful information for Child 1

Name of Child 2

Birthday and Grade completed for Child 2

Allergies, health concerns, or other helpful information for Child 2

Name of Child 3

Birthday and Grade completed for Child 3

Allergies, health concerns, or other helpful information for Child 3

Medical Insurance information:

Medical Insurance Carrier and Policy Number

Name of insurance subscriber

Medical Release

In the event that I cannot give authorization in person, I hereby authorize the staff and volunteers of Good Shepherd Lutheran Church’s Summer Day Camp to administer basic first aid. I understand that the volunteers and staff will contact emergency services in the event of a significant injury. During Summer Day Camp, I give my permission for personnel to administer first aid, transport, or otherwise care for the above-named child(ren) as they deem necessary.

I agree to the above Medical Release

YES

Signed and Dated (please type in your name and today's date)

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