LWCS Summer Camp 2014 REGISTRATION FORM Submit one form per participant. $30 non-refundable registration fee per student is required at time of registration. Registration fee includes LWCS Camp t-shirt. I. General Information Name (Last, First, MI) ___________________________________________________________________________________ Address (Street, City, State, Zip) ___________________________________________________________________________________ Birth date __________________ Age _________ School _____________________________________ Grade in Fall _________________ □ Female □ Male Custodial Parent/Guardian Information Registrant is in the custody of: □ Both Parents □ Mother Only □ Father Only Other: ________________ Mother/Guardian Name __________________________________________________________________ Home Phone ___________________ Cell Phone ______________________ email ___________________ Father/Guardian Name ___________________________________________________________________ Home Phone ____________________Cell Phone _____________________ email ___________________ II. Medical Information Allergies: (Please write "none" if no allergies) ________________________________________________ Medications: List below, with doses and times (Please write "none" if child does not take any medication.) ______________________________________________________________________________________ ______________________________________________________________________________________ Medical Conditions: (Please write "none" if no medical conditions exist) ______________________________________________________________________________________ ______________________________________________________________________________________ Physician name and number_______________________________________________________________ Insurance name and policy________________________________________________________________ Emergency Contact (other than Parent/Guardian) ______________________________________________ Relationship __________________________________________ Home Phone ___________________________ Cell Phone ______________________________ 2013-2014 Health Examination Form on File with Living Word □ Yes □ No OPERATING HOURS/LATE FEES LWCS Summer Camp will run from 7:30 a.m. to 3:30 p.m. Monday through Friday. After Care is available from 3:30 to 6:00 at the cost of $7 per day per child. Children may not be dropped off before 7:30a.m. Children must be picked up by 6:00 p.m. Late fees will be assessed as follows for any late pickups: $5 for the first fifteen (15) minutes beginning at 6:01p.m., $1 per minute beginning @ 6:16p.m. INITIALS ________ PAYMENTS/FEES FEES ARE TO BE PAID IN FULL ON MONDAY MORNING OF EACH WEEK. Fees will be assessed based upon the dates indicated below. Make checks payable to Living Word Christian School. You may also make payments through Renweb. Camp fee will be $100/week or $25/day per child. There is an additional cost for field trips. INITIALS ________ ATTENDANCE/CANCELLATION POLICY Any changes to camp attendance dates (including transferring days or absences) must be given with two weeks’ prior notice. We are not able to give refunds or cancel fees for missed days of camp with less than two weeks’ notice. If your child is unable to attend camp due to medical reasons, you may receive a full refund by providing a doctor’s note. Days may be added with one week’s notice. INITIALS ________ Please circle the weeks and days your child will be attending: May 19 - 23 M May 26 - 30 T W Th F After Care: Y N T W Th F After Care: Y N June 2 - 6 M T W Th F After Care: Y N June 9 - 13 M T W Th F After Care: Y N June 16 - 20 M T W Th F After Care: Y N June 23 - 27 M T W Th F After Care: Y N June 30 – July 4 M T W Th July 7 – 11 M T W Th F After Care: Y N July 14 – 18 M T W Th F After Care: Y N July 21 – 25 M T W Th F After Care: Y N July 28 – August 1 M T W Th F After Care: Y N After Care: Y N T Shirt Size (Circle One): Child: S M L XL Adult: S M L XL XXL ACTIVITY RELEASE I consent for any of my children listed below to participate in any activity or trip sponsored by Living Word Christian Schools Summer Camp. In case of medical need, I authorize Living Word Christian Schools Summer Camp to arrange for medical or dental services for me and any of my children listed below. I agree that any such expense will be my obligation. I, individually, and in my capacities as parent or guardian: _________________________ waive, release, and indemnify Living Word Christian Schools Summer Camp and its agents, directors, employees, and volunteers (collectively, the “Released Parties”) from all claims or liability which have arisen or may arise from any Living Word Christian Schools Summer Camp activity or trip and which involves any damage, loss, or injury to me, my spouse, any of my children, my property, or the property of any of my children. In the same capacities, I promise not to sue any of the Released Parties for any such claims or liability. This waiver, release, indemnification, and promise not to sue, does not apply to claims of criminal conduct or gross negligence. This Activity Release is revocable prospectively only by a writing signed by me which bears the date that the revocation is delivered to Living Word Christian Schools. __________________________________________ Signature __________________________ Date __________________________________________ Signature __________________________ Date Children: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ PHOTO RELEASE I understand that when participating in Living Word Summer Camp activities the registrant may be photographed for print, video or electronic imaging. I understand that the images may be used in promotional and fundraising materials, news releases and other published formats, and will be the sole property of Living Word Christian Schools. Check if registrant MAY NOT: □ Be photographed for Living Word publicity purposes _______________________________________________ __________________________ Signature of Parent/Guardian Date