Fine Arts Christmas

Registration

December 6, 2008

Camper's Name:
 
Last                            First

Date of Birth: (mm/dd/yyyy)        

Grade:3 years old4 years old5 years oldKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade

Parent's / Guardian's Name:
 
Last                          First

Address:
Street
   
               City                                  State

Zip Code

Home Phone Number:

Mother's Cell Phone: 
Father's Cell Phone:

Person(s) my camper may be released to:

Person to contact if parent is unavailable:

Cell Phone Number:

Camper's Physician:

Physician's Phone Number:

Physician's Address:

Statement of Needs:
Please list any allergy, existing illness, previous serious illness, hospitalization, or any medication for prescribed long-term continuous use:

 (Please Check) Should my child need emergency treatment and listed parents or child's physician cannot be located, I hereby give permission for our child to be transported to the nearest doctor, hospital or emergency clinic, and the attending physician has our full permission to render any treatment he or she feels necessary.

Insurance Company: 

Policy Number:

 Willow Meadows Baptist Church and the Fine Arts Camp have my premission to photograph and/or video my child, and use these for publicity purposes such as brochures, websites and video broadcasts.

T-Shirt Size:Youth S.Youth M.Youth LYouth XLAdult S.Adult M.Adult L.Adult XL

I heard about the Fine Arts Camp from:  

I would like to volunteer. 
       Here's my information: 
      

Note to parents who register on-line.  You will be requested to sign a copy of this registration form before leaving your child on the first day of camp.  Thank you.