Alpena Community Ecumenical Vacation Bible School (ACE VBS) First United Methodist First Congregational First Presbyterian Grace Lutheran St Paul Lutheran Trinity Episcopal is hosting… “POWER UP! Living in the Spirit!” VBS DAY CAMP July 27-31, 2015 Each day from 9 AM to 3 PM at: First United Methodist Church 167 S. Ripley Blvd, Alpena 989-354-2490 This is a free event for children Ages 5-12. Lunch and snacks will be provided. Activities include Bible Adventures, Arts & Crafts, Nature Activities, & Games! Registrations can be mailed/dropped off at First United Methodist Church Go to www.alpenafumc.org to print registration. REGISTRATION DEADLINE IS: July 20 2015 Day Camp Registration Form (One Per Child) Child’s name:__________________________________ Child’s Gender:___________________ Child’s age: _________ Date of birth: __________ Last school grade completed: __________ Name of parent(s): _____________________________________________________________ Street address: ________________________________________________________________ City: ____________________________ State: ___________ Zip: _______________________ Home telephone: (_____) _______________ E-mail address:____________________________ cell phone: (____) _____________________ Work phone:______________________________ Home Congregation (church & city)____________________________________________ Parent location while child is at camp (work, home, etc)_____________________________ Name of special friend your child would like to be with: ________________________________ How did you find out about this year’s ACE VBS Day Camp program? (check one) Church  Newspaper Radio Flyer   Mailing TV  Internet/Face Book Other   Name of persons other than parents to whom child may be released. 1._____________________________________ 2.__________________________________ Name of individuals child CANNOT be released. 1._____________________________________ 2.__________________________________  REGISTRATION DEADLINE IS: July 20, 2015 ……………………………………………………………………………………………………………………………………………….…. Crew number or name (for church use only): ________________________________________ Allergies (food, medications or other include insect stings, hay fever, asthma): ________________________________________________________________________ ________________________________________________________________________ Other medical conditions (behavioral, emotional or mental health problems): ________________________________________________________________________ ________________________________________________________________________ Emergency contact person if unable to contact parents: Name_______________________Phone:___________________________ Relationship to child: ___________________________________________ Any activity restrictions?___________________________________________________ Any recent illness, injury, or infectious disease?_________________________________ Additional information_____________________________________________________ _______________________________________________________________________ Insurance Carrier/Plan name & Group #_______________________________________ Has participant had the necessary immunizations to attend school?_________________ Date of last tetanus shot_____________________ Medications to be given while at camp: Medication Dose Frequency Reason for taking medication ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ All medications must be in original containers with participant name on label. THE FOLLOWING MUST BE COMPLETED FOR ATTENDANCE. This health history is correct and complete as far as I know. ______________________ has permission to engage in all camp activities except as noted. The Church leader has permission to provide routine health care & administer prescribed medications. In the event I cannot be reached in an emergency, I give permission to the Church leader to seek emergency medical treatment. I give permission to the physician selected by the Church leader, to secure and administer treatment for the person named above. ___________________________________________ Parent Signature