2016 VBS DAY CAMP REGISTRATION FORM

Registration Deadline Date: June 22, 2016 (Wednesday)
Return completed Registration Form to: Beautiful Savior Lutheran Church
12513 SE Mill Plain Blvd Vancouver, WA 98684 ] 360-254-9243
2016 VBS DAY CAMP REGISTRATION FORM
Camper’s Name (first and last): _________________________________________________________________________
Grade Completed (as of camp) ______
M ( ) F ( ) Birthdate _________________ Age as of camp_____
Parent /Guardian Name:______________________________________________________________________________
Mailing Address ______________________________________City_______________________ St _____ Zip_________
Day Phone _______________________Night __________________________ Cell ___________________________
Email Address ___________________________________________________
Home Church __________________________ City _______________________________
IN CASE OF EMERGENCY, PLEASE NOTIFY:
Name _______________________________________________________________________________________
Address _________________________________ City_______________________ St ______ Zip ______________
Day Phone _____________________ Night ___________________________ Cell _______________________
Relationship to camper ____________________________________________________________
APPROVED DRIVER:
Name of Person(s) picking up the child:____________________________________________________________
Phone Number of Approved Driver: _______________________________________________________________
Relationship to Parent and Child:_________________________________________________________________
List days to be picked up:_______________________________________________________________________
My Child has permission to walk home, ride a bike home from Day Camp _____YES _____NO
Parent/Guardian Signature:______________________________________________ Date:_____________________
ALLERGIES: Type of Allergy
No Yes
Food
No Yes
Medication
No Yes
Environmental
No Yes
Other
No Yes
(animal, plant, insect, etc.)
(please circle)
Describe/Specify Allergen
Type of Reaction: Please mark which apply
Mild
Moderate (Swelling
or severe rash)
Severe
(Difficulty Breathing)
Does your child have any special needs (behavioral and/or physical) we should know about? (please feel free to expand on back)
__________________________________________________________________________________________________
I hereby give informed and expressed consent for my child to take part in all camp activities under supervision, and agree that the Day
Camp or Day Camp personnel will not be held responsible for accidents arising there from. I authorize the Day Camp Healthcare
Provider and/or designated Day Camp staff/volunteer to provide appropriate treatment to my child for injuries and/or illness. I
understand that the information on this form may be released to the appropriate medical personnel in case of medical emergency. I also
understand the failure to disclose medical or emotional problems in advance may lead to serious consequences while at Day Camp.
Lastly, I verify that everything contained on this form is complete and accurate, to the best of my knowledge.
I also consent to the use of any photograph of my child or family in future Lutherwood publications.
*A copy of this form will be shared with Camp Lutherwood, Oregon at the end of the Day Camp week.
Parent/Guardian Signature: _________________________________________________ Date: ___________________