June 22 – 25, 2015 Please Type or Print Student Name M F Age Grade in Fall Parent/Guardian Preferred Phone Work Phone Email Emergency ContactPhone Work Relation to student Dietary Needs/Concerns Food allergies/medications Medications taken during the day Permission to walk to Freeway Park for recreation crossing 6th Ave. with supervision: Yes Permission to photograph: Music Lessons: Yes School No No Private Instrument #Years of lessons Student’s special interests and gifts Are you registering a sibling? If so, what name? How did you hear about the camp? T-Shirt Size (all youth sizes) XS (2-4) S (6-8) M (10-12) L (14-16) Tuition Paid Scholarship Received Total Parent Signature Date Submitted Questions? Call Rosemary Hashimoto: 206.290.0502 or Plymouth Church: 206.622.4865 [email protected] XL (18-20) Medical Authorization and Insurance Information In order to insure that my son/daughter, is given prompt medical attention, if it should ever be necessary, I authorize the staff of Plymouth Church, United Church of Christ to consent to medical treatment, including x-rays or other diagnostic procedures or hospitalization, which may be advised by any physician licensed to practice medicine in any state of the United States. It is understood that if time and circumstances reasonably permit, the Plymouth Church UCC staff will try, but not be required, to communicate with the undersigned prior to any such medical treatment or hospitalization. Date Parent/Legal Guardian Signature This is to let you know that my son/daughter has insurance that will cover medical treatment or hospitalization for injuries sustained while participating in a Plymouth Church UCC activity under an insurance policy which is paid for by me or my employer. The name of our accident or medical insurance company is: Group # Policy # ………………………………………………………………………………………………………………………………… Permission Slip I give permission for my son/daughter to cross, with supervision, 6th Avenue at University Street, Seattle, WA, to participate in recreation activities sponsored by Plymouth Congregational Church, United Church of Christ through its staff and leaders. I agree to release and agree to hold harmless Plymouth Church UCC, its staff and leaders, from any personal liability, not covered by insurance, arising from injury to my minor child. Date Parent/Legal Guardian Signature