Summer Clubhouse Registration | St. Luke's United Methodist Church

Child's Full Name

First Last

Gender

Birthday

School (Fall '18)

Grade (Fall '18)

Home Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Phone

Allergies

Parent 1 Name

First Last

Parent 1 Home Phone #

Parent 1 Cell Phone #

Parent 1 Work Phone #

Is Parent 1's address different from the child's?*

Yes
No

Parent 1 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent 1 Email address

Parent 2 Name

First Last

Parent 2 Home Phone #

Parent 2 Cell Phone #

Parent 2 Work Phone #

Is Parent 2's address different from the child's?*

Yes
No

Parent 2 Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent 2 Email address

Emergency Contact Name

First Last

Emergency Contact Phone #

Emergency Contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Doctor's Name

First Last

Doctor's Phone Number

Doctor's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

All campers are required to have immunization and shot records prior to the beginning of camp. Records must be current and on file at camp. No camper will be allowed to attend without these records.

Please check ALL that apply

Week 1 - June 25-29: "Love in My World"
Week 2 - July 2-6: "Sports & Fitness" (closed July 4)
Week 3 - July 9-13: "Science & Technology"
Week 4 - July 16-20: "Me & My World"
Week 5 - July 23-27: "Mosaic Music Camp"
Week 6 - July 30-Aug 3: "Love in a Big World"

St. Luke's United Methodist Church:

Member
Visitor

I have received the Parent Handbook for St. Luke's Summer Clubhouse
I have provided a copy of my child's current immunization records to St. Luke's summer Clubhouse

Signature

Date

Pick Up Authorization

Child Name

First Last

Grade (Fall 2018)

School

Child's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Parent 1 Name

First Last

Work Phone #

Home Phone #

Cell Phone #

Parent 2 Name

First Last

Work Phone #

Home Phone #

Cell Phone #

Emergency Name

First Last

Work Phone #

Home Phone #

Cell Phone #

Emergency contact Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

May never pick up my child:

Authorized to pick up your child from St. Luke's Summer Clubhouse

Name

First Last

Phone

Name

First Last

Phone

Name

First Last

Phone

Name

First Last

Phone

Name

First Last

Phone

Please complete the following information

Marital Status of Parents

Married
Separated
Divorced
Other

List any NON MEDICAL special needs or other important information that staff should know about your child

Custody/Visiting Arangements:

Allergies

Yes
No

Asthma

Yes
No

If yes, please list all allergies and their severity. Please see the front office to request an Allergy Action Form

Program Activities:

I hereby give permission for my child to use all of the play equipment and participate in all of the activities of St. Luke's Summer Clubhouse

Field Trip Permission:

I hereby give permission for my child to participate in the St. Luke's Summer Clubhouse Field trips **Please Note: Parents will receive active reminders at the beginning of the week**

Permission for Transportation

I hereby give permission for my child to be transported by the St. Luke's Summer Clubhouse.

Permission for Water Activities:

I hereby give permission for my child to participate in all water activities (Sprinklers and less than 2 feet of water)

Publications & Media

I hereby give my consent for photographs and/or videos taken of my child to be used for education purposes, teacher training, or publicity of St. Luke's Summer Clubhouse

Child's Name

First Last

Grade Fall '18

Parent Name

First Last

Date

Signature

Authorization for Medical Care

If I cannot be reached to make arrangements for medical care for my child at the time of an illness or accident, I give permission for St. Luke's United Methodist Church Summer Clubhouse 1. To call 911, and 2. To transport to Texas Children's Hospital, or 3. To transport to the hospital of my choice.

Hospital of my choice

Child's Name

First Last

Family Health Insurance

Policy Number

And/ or ID Number

Parent Signature