--------------Registration Form 2012-------------
Crestfield Daycamp
Camper’s Name:
Last____________________ First_________________
Address_____________________________________________
City________________ State________________ Zip_________
Home Phone_________________________________________
Cell Phone___________________________________________
Age____ M/F____ Date of Birth____________________
Grade in Fall 2012_____________________________________
Email_______________________________________________
Custodial Parent(s)/ Guardian:
Please circle preferred parent or guardian to contact during camp
Name__________________________________________________________
Day Phone__________________ Evening Phone_______________________
Name__________________________________________________________
Day Phone__________________ Evening Phone________________________
My child is in the custodial care of (check one):
___both parents ___mother only ___father only Other____________________________
May your child be released to anyone other than the custodial parent/guardian? ___ yes ___ no if yes please list:_______________________
Emergency contact if parents cannot be reached:
Name_______________________________
Day Phone___________________________
Evening Phone________________________
Cell Phone___________________________
Does your child have any food, drug or stinging insect allergies? YES NO (circle)
If yes, please identify__________________________________________
Is your child currently taking any medication? YES NO (circle)
If YES, please identify__________________________________________
Are you currently a member of a church? If so, please provide the name:
____________________________________________________________
We learned about day camp from:________________________________
Permission to participate
I understand the nature of the activities and the health and safety measures. I give permission for my child to attend and participate in activities on the church property.
I give permission for my child to be photographed/videotaped and for the camp to use the pictures for publicity purposes. I understand and agree to cooperate with all regulations and procedures.
Parent/guardian signature:__________________________ Date:_____________
