Adventure Summer Camp Registration - Pine Shores Presbyterian Church

$300/week or $60/day (Early registration discount if paid by Dec 1 $250/week or $$50/day).

1st Child\'s First Name

1st Child\'s Last Name

1st Child\'s Age

1st Child\'s Date of Birth

1st Child\'s School

1st Child\'s Grade this school year 2022/2023

1st Child\'s Gender

2nd Child\'s First Name

2nd Child\'s Last Name

2nd Child\'s Age

2nd Child\'s Date of Birth

2nd Child\'s School

2nd Child\'s Grade this school year 2022/2023

2nd Child\'s Gender

3rd Child\'s First Name

3rd Child\'s Last Name

3rd Child\'s Age

3rd Child\'s Date of Birth

3rd Child\'s School

3rd Child\'s Grade this school year 2022-2023

3rd Child\'s Gender

Person to Contact in Emergency: Parent/Guardian

First Name/Relationship

Last Name

Parent/Guardian Home or Cell Phone

Parent/Guardian Work Phone

Address

Apt, suite, etc.

Country

City

State

Zip code

Parent/guardian Email

Pine Shores Member

Other Church

Second Contact/Relationship

Name, home, work and cell phone numbers please.

Third Contact/Relationship

Name, home, work and cell phone numbers please

Medical History

Please list any allergies, illnesses, current medications and diet restrictions and explain. If none, please answer \"none\"

Does your child have any limitations that will require adaptations to the program or field trip?

Please answer Yes or \"none\" (if yes, please explain.)

Field Trip and General Release

Yes

My child has my permission to attend all field trips included in the Day Camp under the supervision of Pine Shores Presbyterian Church. I read, understand and agree with the following conditions: - All campers will be participating in the field trips. If my child arrives late or leaves early, I will be responsible for taking him/her to and from the field trip site and making prior arrangements with the Camp Director. - Proper attire and sun protection will be needed and I will provided the aforementioned as necessary. - All campers shall follow the established program and guidelines. Public school policies of attire and safety apply. Any campers can and will be expelled from the program due to disciplinary misconduct, with no camp refund. - The parents and/or guardian, in consideration for Pine Shores Presbyterian Church providing facilities, instruction and supervision in the registered activity, does hereby: (a) assume all risk of possible damage or injury involved through participation of my child in the registered activity, (b) request permission to have my child participate in the activity with full knowledge that said activity could result in damage or injury to participant. - I give my permission for use of photography including my child in church publicity. - I understand that registration fees are non-refundable.

Is there any other information you wish to share with us?