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ST. JOHN'S LUTHERAN CHURCH
KIDS'CONNECTION PART 1: GENERAL INFORMATION 1. Child's Name __________________________________________________ 2. Address ___________________________________________________________________________________ 3. City
_______________________________ Zip
_______________ 5. Birthdate _______________________ Last grade completed ___________________________ 6. Child lives with ___________ a) Mother ______________b) Father c) ________________both parents 7. Father's name ________________________________________________________________________________ Work address ___________________________________________ Work and/or cell phone _________________ 8. Mother's name __________________________________________ Work address ___________________________________________ Work and/or cell phone _________________ 9. Please note the party financially responsible for fees: _________________________________________________ 10. Please note any special custody arrangements the camp needs to be aware of: ___________________________ 11. Note any physical, emotional, or psychological
needs (including medication and handicaps): _________________ 12. Names of persons other than parents who are
authorized to pick up your child from day camp: _______________________________________________________________________________________________
FEE SCHEDULE: Weekly: $125.00 Daily: $30.00 Registration Fee: $40.00 per family T‑SHIRT: $10.00 T‑SHIRT SIZE: Youth S M L XL Adult S M L XL
· Weekly fees for the second child in a family are $115.00. · Camp fees are due no later than the MONDAY prior to the week your student is enrolled. · Summer camp is available on a prepaid basis only. Children will not be admitted until fees have been paid. · Once a child is signed up for specific days, these days cannot be changed or refunded due to staffing and field trip planning. There will be no exceptions. · Late enrollment after that time is on a space available basis and is charged at the weekly rate of $140. · Enrollment is on a first‑paid, first‑enrolled basis; forty children per week.
Please indicate the weeks that you are planning to enroll. Children will be officially registered for the week when summer camp fees for that week are received in the church office.
_____June 26‑June 30 _____*July 5‑July 7 ($90) _____July 10‑July 14 _____July 17‑July 21
_____July 24‑July 28 _____July 31‑August 4 _____August 7‑August 11 PART 2: ST. JOHN'S LUTHERAN KIDS'CONNECTION 2006 AGREEMENT
Listed below are the agreement statements and release statements for parents/guardians whose students attend ST. JOHN'S SUMMER CAMP. Please carefully consider each one and signify your agreement by signing and dating this form.
1. We agree to accept all regulations and policies at St. John's Summer Camp and St. John's Lutheran Church on behalf of ___________________________________________________. (Student’s name)
2. We agree to pay our financial obligations to St. John's Summer Camp on or before the due date. Summer Camp fees are due on each Monday prior to the week your student is enrolled.
3. We authorize the office personnel to seek emergency treatment as may be necessary (in the opinion of the attending physician) if parents cannot be reached.
4. We authorize St. John's Staff to use the discipline (corporal punishment excluded) it deems wise and expedient for our child. If our child does not conform to the standards by those in charge of the Summer Camp, he or she may be excluded from the program.
5. We give permission for our child to take part in all summer day camp activities including sports and camp-sponsored trips away from the school. We absolve St. John's Lutheran Church/Summer Camp from any liability for our child because of any injury to him/her at camp or during any camp activity.
6. We understand that St. John's Lutheran Church/Summer Camp reserves the right to dismiss any student who does not respect its spiritual standards or cooperate in the educational and summer camp process.
7. We understand that Kids' Connection Summer Camp reserves the right to use our child's picture in all future publicity, unless otherwise notified by the parent/guardian.
Signature of Parent/Guardian _____________________________________ Date ______________________
St. John's Lutheran Church admits students of any race, national and ethnic origin to the rights, privileges, programs, and activities generally accorded or made available to students at the school. We do not discriminate on the basis of race, color, national or ethnic origin in administration of our educational policies, admission policies, athletic or any other school administered programs.
PART 3: OFF‑CAMPUS ACTIVITY RELEASE
(Camper's name) _________________________________________________ has my permission to participate in KIDS'CONNECTION 2006 field trips sponsored by St. John's Lutheran Church.
St. John's Lutheran Church and School has permission to provide transportation (camp staff and parent volunteers) for all field trips during Kids' Connection 2006 Summer Camp. I believe that the necessary precautions and plans for the care and supervision of the children during the trips will be taken. Therefore, I will not hold St. John's Lutheran Church, owners, and drivers of the vehicles, or those supervising the trips, responsible for any accident. Permission is given for emergency medical treatment for my child.
In case we cannot be reached, please contact:
Name_____________________________ Relationship ______________ Phone #: ______________
Name_____________________________ Relationship ______________ Phone #: ______________
Physician's Name _________________________________________________ Phone #: ________________
Insurance Company _______________________________________________ Policy #: ________________
Signature of Parent/Guardian: ______________________________________ Date: __________________
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