CONSENT TO MEDICAL TREATMENT ADVENTURE WEEK As the parent, legal guardian, or agency representative, I hereby give consent to Clairemont Covenant Church to provide all emergency medical or dental care prescribed by a duly licensed physician (M.D.) or dentist (D.D.S.) for: (Child’s Name) This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent. Signed: Date: Please list any medical conditions that may prevent participation in any of the activities of Adventure Week: 2015 Any food allergies: Please return form & payment to: Clairemont Covenant Church 5255 Mt. Ararat Dr. San Diego, CA 92111 858-279-6130 Sponsored By: Clairemont Covenant Church Children’s Ministry Registration form Journey Off The Map June 29 - July 3 9am - 12:30pm Daily (There is a snack for the campers, but lunch is not provided) Adventure Week is for students entering grades K-6 in the Fall of 2015 Registration Fees: Early (On or before May 31) - $50 Regular (June 1 - June 28) - $55 Late (June 29th) - $60 **We cannot guarantee preferred shirt size for campers who sign up after June 5th Camper’s Name: Gender: M F Age: Grade entering in the Fall of ’15: School: Would like to be in a group with: (Please list only one other camper – must be within one grade of registrant) Camper’s Address: Name of parent(s) or guardian(s): Email: Daytime Phone: Cell Phone: Individuals (other than parents) who are allowed to pick up: Payment can be made by cash, check (made payable to “Clairemont Covenant”) or online at our website (www.clairemontcov.org). *If you are registering more than one child from the same family, there is a $5 discount per child during the “early” and “regular” registration periods. No discounts will be applied during the “late” registration period. In case of emergency (and parents cannot be reached) contact: Name: Phone #: T-Shirt Size (circle one): Child: Small Medium Large Adult: Small Medium Large