1. technology and computing
2. consumer electronics
3. telephones
4. mobile phones

For office use only:
Date Received______________
Registration fee_______Ck#_______
Student Registration
Ministry 22:6-Summer Day Camp 2015
First United Methodist Church Mocksville
Name
Male/Female
Grade Entering
Birth Date
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Birth Date
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Birth Date
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T-Shirt size: Child – S M L XL Adult – S M L XL
School__________________________________
Name
Male/Female
Grade Entering
T-Shirt size: Child – S M L XL Adult – S M L XL
School__________________________________
Name
Male/Female
Grade Entering
T-Shirt size: Child – S M L XL Adult – S M L XL
School_________________________________
Registration Fee $25/per child
Part Time (up to three days) ________ $60
Full Time (four or more days)________$100 for first child, $90 for each additional child
If you know what weeks your child is attending, please indicate here:
Home Phone
Address
Mother’s Name
City
Work Phone
Zip Code
Cell Phone
Address (if different from student/father)
Father’s Name
E-mail address:
Work Phone
Address(if different from student/mother)
Cell Phone
E-mail address:
If parents cannot be reached, in an emergency call:
Phone(s)
Family Doctor
Relationship to child
Phone
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Hospital Preference
Insurance Carrier and policy number
Does your child take daily medications?
If so, please list them and reason for taking the medication:
Does your child have allergies or any medical conditions that our staff should be aware?
___________
Name of person (s) who have permission to pick your child up from after school care:
Name
Relationship to Child
Phone #
_________________________________________________________________________________________
Name
Relationship to Child
Phone #
_________________________________________________________________________________________
Name
Relationship to Child
Phone #
How would you describe your child’s personality? How does he interact with other children? Adults/authority?
Please share with us any information that would be helpful to us in insuring your child has a great after school
care experience: (i.e. interests/hobbies, dislikes, has two families/homes and may have a difficult time after
coming back from the other home, etc. )
POLICIES
Payments
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Payment is due one week in advance for the week that the student will be attending. This allows us to schedule
and plan appropriately.
Registration is $25 per student.
June 11th is $20.
Full time tuition is $100/week/first child and $90/week/each additional child. Part time tuition is $60/child/per week
Full time student Accounts that are paid in full by May 31, 2015 will receive a 10% discount.
Account balances that are late are subject to a late fee.
If your bank returns a check due to insufficient funds, immediate payment is due to keep your child’s account up to
date. A $25 fee will be charged for each returned check. If you have two returned checks in a 6-month period, you
will no longer have check privileges and will be required to pay program fees in cash, in advance.
Non-attendance does not entitle you to a refund regardless of illness, vacation, or weather cancellations.
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Permissions
Emergency Care/First Aid
____ I give permission for the Director of First United Methodist Church Childcare Ministries or other personnel
designated by the Director, to give or authorize emergency medical treatment or first aid or to take my child to a
doctor or to the ER if necessary. I will not hold First United Methodist Church Childcare Ministries, or any staff
of the church or after school care responsible in the event of an accident, injury, loss, or death.
____NO
Parent /Guardian Signature
Date
Media
____I permit FUMC and its Childcare Ministries to publish images of my child(ren) in internal and external
material including printed material, print advertising, and promotional videos, and to Publish pictures and videos
on the First United Methodist website or Facebook page. I also permit the use of my child(ren)’s image in
broadcast and print media news coverage of FUMC. This includes but is not limited to Davie County Enterprise,
DavieLife, Facebook, and the church website. I understand that my child’s name is not published.
____No, FUMC does not have my permission to use images of my child.
Movies
____I permit my child to watch PG movies.
____No, I do not want my child watching PG movies.
Transportation
___I permit my child to be transported in the First United Methodist Church Blue Bird Bus to field trips. I
understand that either a certified staff member or certified member of the transportation committee from First
United Methodist Church Mocksville will be the driver. These include but are not limited to July 1st to Dan
Nicholas Park in Salisbury. July 15th to Asheboro Zoo, July 29th to the Winston-Salem Dash game, August 6th to
Statesville Leisure Pool, and August 13th to Sci- Works in Winston Salem. I also permit my child to ride the bus
to Mocksville Elementary School for lunch on days that it is deemed too hot or rainy by the Director and staff. I
understand that if my child is under 40 pounds, I am required to provide a 5 point car seat to FUMC Ministry
22:6 to use for transportation purposes and that if my child is over 40 pounds that they will be using a lap belt to
secure their place in the bus. I also understand that my child will have a picture identification made of them to
use while on the bus in the event that identification is needed of them in the event of an accident or emergency.
___I DO NOT permit my child to be transported by FUMC Ministry 22:6.
___I permit my child to walk to Mocksville Elementary for breakfast and/or lunch, to Rich Park, and to the library,
as well as to Somerset Nursing Home behind the Family Life Center. I permit my child to do this on planned
days as well as days that the opportunity may arise for this to be done as deemed appropriate by the director
and staff.
___I DO NOT permit my child to walk to any location outside of the campus of FUMC Mocksville.
Other
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Participants are responsible for their own accident insurance while attending First United Methodist
Church After School Care or Summer Day Camp.
FUMC is not responsible for any items that are lost or stolen.
FUMC does not normally administer any medications and will only do so when proper documentation is
in place giving that permission. However, in the event of an emergency in which the parent cannot be
contacted, Emergency Medical Staff and FUMC may take the appropriate action in the best interest of
the child.
I have read, understand, and agree to all the policies stated above and know that additional information on
these policies can be found in the Family Handbook.
_________________________________________________________________________________________
Parent/Guardian Signature
Date
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