Camper's Name *

First Name

Last Name

Daytime Phone *

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Cell Phone *

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Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Doctor/Healthcare Provider Phone *

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Date of last Tetanus booster: *

MM

DD

YYYY

I authorize the following people to pick up my child from Day Camp. If there are any changes in these arrangements, I will give advance written notice. (Note: If there are any special instructions, or any persons who are not authorized to pick up your child, please make a specific note on the next part.) *

First Name

Last Name

Phone *

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Name

First Name

Last Name

Phone

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Parent Signature *

Release: To the best of my knowledge, all registration and health information for the child described herein is correct. I give permission for my child to participate in all related activities and programs for the week and agree that Westminster Presbyterian Church, as well as staff and volunteers from the church, will not be held responsible for accidents or personal injury arising from participation therein. I authorize the adult leaders from Westminster Presbyterian Church to secure any medical or emergency treatment deemed necessary for my child. I also give permission for my child to be transported in the vehicles of adult staff and volunteers associated with the VBS Day Camp Program. As the above named child’s parent/guardian, I am the primary carrier of accident/health insurance for my child. I also grant permission for photos or video taken of the child listed above to be used in publications and promotional materials by Westminster Presbyterian Church.

First Name

Last Name