Download the 2013 Summer Camp Registration Form

Saint Vincent de Paul School
SUMMER CAMP 2013
Registration
Child’s Name: ____________________________ DOB: _____________________
Child’s Name: ____________________________ DOB: _____________________
Home Address: ___________________________ Phone: ___________________
___________________________ Religion:__________________
Mother/Guardian
Father/Guardian
Name: ____________________________ Name: ________________________
Employer: _________________________ Employer:______________________
Work Phone: _______________________ Work Phone: ___________________
Cell/Pager: _________________________ Cell/Pager: _____________________
E-mail: _____________________________ E-mail: ________________________
Does your child have allergies? ______ If yes, please list:_____________________
___________________________________________________________________
Does your child have any medical condition that would necessitate a staff
member administering medication? _____ If yes, please explain:______________
___________________________________________________________________
I authorize the following individuals to sign out my child from St. Vincent de Paul
Summer Camp:
Name__________________________
Name__________________________
Name__________________________
Name__________________________

Emergency Care
If I/we cannot be reached immediately in an emergency, I/we delegate full
authority and temporary care of the child to the following local relatives,
neighbors, or friends:
Name: ______________________________ Relationship to child: _____________
Address: _______________________________________ Phone: _____________
Name: ______________________________ Relationship to child: _____________
Address: _______________________________________ Phone: _____________
In case of emergency, I/we authorize St. Vincent de Paul EDP to call the physician
listed (or another if s/he cannot be reached) and follow his/her instructions:
Physician: __________________________________________ Phone: _________
Choice of Hospital:
___________________________________________________________________
I/we authorize the St. Vincent EDP to call an ambulance or paramedics or fire
department, and to follow instructions given. The St. Vincent EDP does not
assume any responsibility for the above emergency procedures and does not
assume payment for measures taken.
I agree to all statements given on this application.
Parent/Guardian Signature: ________________________________________
Date: ________________
Non-refundable $30.00 fee per child
is due upon submission of registration.
Date Rcvd: ___________
Check #/Cash: ________
Amount Rcvd: ________