Adventure Camp Registration - Pine Shores Presbyterian Church

$250/WEEK or $50/day if registered and paid by December 1st ($300/week or $60/day after Dec. 1st)- FILLED!!!

Schedule *

Check if you want Mon, Jan 2 ($50 if paid by Dec 1, $60 after) FILLED

Check if you want Tues, Jan 3($50 if paid by Dec 1, $60 after) FILLED

Check if you want Wed, Jan 4 ($50 if paid by Dec 1, $60 after) FILLED

Check if you want Thur, Jan 5($50 if paid by Dec 1, $60 after) FILLED

Check if you want Fri, Jan 6 ($50 if paid by Dec 1, $60 after)FILLED

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 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 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 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? Are there any issues of which we need to be aware? *

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.

Any additional information you would like us to know? If not, type "none". *

Any additional information you would like us to know? If not, type "none".