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Summer Day Camp Registration

Kids Entering 1st thru 5th Grades
June 26th thru June 30th from 9am - 3pm

9am – 3pm ($65 week fee)
9am – 3pm ($40 sibling week fee)
3pm – 5pm ($15 additional day per child fee)

"PLEASE FILL OUT A FORM FOR EACH CHILD"

Child First Name(*)
Please type the child's first name.

Child Last Name(*)
Please type the child's first name.

Date of Birth(*)
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Grade(*)
Please tell us the grade the child will be entering in August.

Parent or Guardian First Name(*)
Please type the Parent or Guardians first name.

Parent or Guardian Last Name(*)
Please type the Parent or Guardians last name.

Phone Number(*)
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E-mail(*)
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Allergies or Special Attention
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If needed, please list someone other than the Parent/Guardian listed above authorized to pick up your child if the Parent/Guardian is not available for child(ren) pickup:
Other First Name
Please type the persons first name who will be picking up the child.

Other Last Name
Please type the persons last name who will be picking up the child.

Other Phone Number
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Total Children Registering(*)
Please tell us the grade the child will be entering in August.

Insurance Carrier(*)
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Policy Number(*)
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Family Physician(*)
Please type the Family Physician if Available

Physician Phone Number(*)
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Authorization to treat: I authorize Margie Santiago, and/or Michelle Torres (Camp Directors) to approve medical attention for my child(ren) in the event of an emergency during the time they are in our care. I am fully aware of all of the risks included during the water and outdoor activities at Freedom Christian Fellowships VBS Day Camp. I do not suffer from any medical condition or disease that may in any way hinder or prevent me from fully participating in physical activity. I have fully disclosed all pertinent medical and physical conditions to Freedom Christian Fellowship Chapel prior to signing this waiver. I hereby knowingly and intentionally waive any and all claims against Freedom Christian Fellowship Chapel arising from or relating to my participation in activities conducted by Freedom Christian Fellowship AG, 3423 Loretto Road, Jacksonville, FL 32223.

Initials or Signature(*)
Signature Required

Date(*)
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(*)

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