Camp Registration – Light Of The World

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JLSCC Summer Day Camp Registration Form

Instructions 1. One registration form per participant. 2. Must be complete by a parent or legal guardian. 3.$35 registration fee per child. 4. $100 per week for first child and $75 per week for each additional child. 5.You may pay for the entire nine weeks up front at the times of registration. 6. Please make checks payable to JLSCC. 7. There will be an additional charge of $20 if registering after deadline date.
Weekly Registration *
Please check the week(s) that the participant will be registered for the summer camp.May 26 - 29June 1 - 5June 8 - 12June 15 - 19June 22 - 26July 6 - 10July 13 - 17July 20 - 24July 27 - 31
Participant's First Name *
Participant's Last Name *
Age *
Birthday *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Sex *
MaleFemale
Home Phone *
Email *
T-Shirt Size *
Are you a Light Of The World Christian Tabernacle member? *
YesNo
Please Note: We will not be able to exchange T-shirts from the sizes stated on registration form.
Parents Initials *
**Fees only include education field trips and snack. Entertainment Field trips (swimming, movies, etc.) are not included** Please complete section below by filling in parental or guardian information.
First Name *
Last Name *
Relationship *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Home Phone *
Work Phone *
Mobile Phone *
List any other sibling(s) that will be attending the Summer Day Camp: *
EMERGENCY NUMBERS: Please give the name, address and phone number of two people that may be notified in case of emergency or illness, when parents or guardian are not available. These people should live within 40 miles of 30281. Please provide a telephone number where these people may be reached during program hours.
Emergency Contact 1 First Name *
Emergency Contact 1 Last Name *
Relationship to child *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Home Phone *
Cell Phone *
Emergency Contact 2 First Name *
Emergency Contact 2 Last Name *
Relationship to child *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Home Phone *
Cell Phone *

PARTICIPANT'S PHYSICIAN

Physician's First Name *
Physician's Last Name *
Phone *
Address *
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry
Please list the name of your major medical health insurance company: *
Is the Participant covered under this health insurance company? *
YesNo
Please list any medications participant is currently taking: *
Will the participant be taking medication during Summer Day Camp? *
(If yes, then please fill out the Authorization for Medication Form)YesNo
List any known allergies: *
Does the participant have any special needs that would keep him/her from participating in activities with a group or other children? *
If so, what would your child need to enable him/her to participate?
Is there any other information you would like to give us about your child to help us better care for him/her? *
Please Note: If your child requires one-on-one assistance, or any other type of special attention, presently our facility is not equipped to handle special needs children at this time.

ACKNOWLEDGEMENT OF HANDBOOK

By signing below, I acknowledge that I have received a copy of the Summer Day Camp Handbook and I also agree to all the rules set forth in the Handbook.
Signature: *
Date *

PAYMENT POLICY

Please initial these payment policies:
*I have registered for and paid a NON-REFUNDABLE deposit per week that my child is attending camp.
*I understand there will be an additional $35.00 charge per registration change.
*I understand the balance is due for each specific week by the close of the business day of the deadline payment schedule. There will be no exceptions.
*I understand if the balance is not received by deadline payment date my child will be automatically dropped from the summer program for the particular week. No exceptions. The late payment fee is $20.
*I understand that the deposit cannot be applied to another week.
*I understand the payment cannot be applied to another week if I decide not to have my child attend for that week.

CAMPER RELEASE

Persons Authorized to Pick Up Your Child in Addition to Parents/Guardians already listed:
Full Name *
Phone *
Full Name *
Phone *
Full Name
Phone
Full Name
Phone
This form can be changed/updated at any time during the Day Camp Program. Your child will not be released to anyone not on this list without written permission from you. If anyone is forbidden by law from having custody of your child, we must have a copy of the restraining order on file.

Verification

Please enter any two digits *Example: 12
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