Parent/Guardian Name(s) ___________­__________________________________________

Address: _________________________________________­­­________________________

Phone:­­­___________________________________________________________________

Email: ­­­­­­­­­­­­­­­­­___________________________________________________________________

 

I, _______________________________________, the custodial parent/ guardian for _________________________________­________, give permission for my child/children to attend Make a Difference Camp. I understand that my child/children will receive the utmost care; however, in the event of an emergency, I authorize those volunteering on behalf Central Congregational Church to seek and obtain medical care for my child/children.

Parent or Guardian Signature: _______________________________________________

Date: _______________________________________________

 

I give permission for my child/children’s photo (without his/her name) to be shown on Central Congregational Church’s bulletin boards, Facebook page, and website.

Yes ____     No ____

 

Emergency contacts if the above parent/guardian cannot be reached.

1st Emergency Contact: ____________________________  Phone:___________________

2nd Emergency Contact: ____________________________  Phone:___________________

 

Please list everyone who is allowed to pick up your child/children.

________________________________________________________________________________________________________________________________________________

 

Child’s Name: __________________________________   Age:_______  Grade: _______

T-Shirt Size (circle one) –   Youth Sm     Youth Med     Youth Lg     Youth XL

Adult Sm      Adult Med      Adult Lg       Adult XL       Adult XXL

Do we need to know anything about your child’s health to ensure his/her safety? (e.g. uses an inhaler, has seizure disorder, special needs etc.)

________________________________________________________________________

Does your child have allergies? (i.e.: food or medicine)

________________________________________________________________________

­­­­­­­

 

Child’s Name: __________________________________   Age:_______  Grade: _______

T-Shirt Size (circle one) –   Youth Sm     Youth Med     Youth Lg     Youth XL

Adult Sm      Adult Med      Adult Lg       Adult XL       Adult XXL

Do we need to know anything about your child’s health to ensure his/her safety? (e.g. uses an inhaler, has seizure disorder, special needs etc.)

________________________________________________________________________

Does your child have allergies? (i.e.: food or medicine)

________________________________________________________________________

 

Child’s Name: __________________________________   Age:_______  Grade: _______

T-Shirt Size (circle one) –   Youth Sm     Youth Med     Youth Lg     Youth XL

Adult Sm      Adult Med      Adult Lg       Adult XL       Adult XXL

Do we need to know anything about your child’s health to ensure his/her safety? (e.g. uses an inhaler, has seizure disorder, special needs etc.)

________________________________________________________________________

Does your child have allergies? (i.e.: food or medicine)

________________________________________________________________________