Registration Form - South Hope Community Churchs Day Camp - Summer 2013

Name____________________________ Address_____________________________________ City__________________________ State________ Zip__________ Phone________________ Age____ Birth date_______ Entering grade____ Church_______________________________ Parent or Guardian________________________ Phone__________________ Please provide an emergency contact in case you cannot be reached. Emergency Contact_______________________ Phone_______________ SHCC reserves the right to use your childs picture taken at Day Camp for advertising purposes. Please check this box if you do not want your childs photo used.
HEALTH HISTORY (giving approximate dates) 1. Please list all allergies and health concerns.

Childs Name______________________
In the event I cannot be reached in an EMERGENCY, I hereby give permission to the physician or hospital selected by the Camp Director to hospitalize, secure proper treatment for, and to order injection, anesthesia, or surgery for my child as named above.

2. Is Your Child taking any medications? Yes No *If yes, please list.

PARENT'S SIGNATURE*
3. Is your child current on all immunizations? Yes No

_____________________________________ Printed Name__________________________ Date______________

*Required for those under 18; to be signed by parent or guardian in ink.

4. Has your child been under a physicians care in the last 6 months? Yes No * If yes please explain

Please return completed form to: South Hope Community Church 142 Main Street Hope, Maine 04847