Messiah Lutheran Church and School

Summer Day Camp Program for School Aged Children 2017




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To be used for demographic purposes only.


If other siblings will be enrolled, please complete this field.


If other siblings will be enrolled, please complete this field.










This is the first person we will contact in an emergency.




Please enter your street address.


Please enter your city.


Please enter your state.


Please enter your zip code.


Please enter your cell phone number (xxx-xxx-xxxx).


Please enter your home phone number (xxx-xxx-xxxx).


Please enter your work phone number (xxx-xxx-xxxx).


Please enter your work name and address.


This is the second person we will contact in an emergency.




Please enter your street address.


Please enter your city.


Please enter your state.


Please enter your zip code.


Please enter your cell phone number (xxx-xxx-xxxx).


Please enter your home phone number (xxx-xxx-xxxx).


Please enter your work phone number (xxx-xxx-xxxx).


Please enter your work name and address.





Children will only be released to those listed on this form unless notified in writing. Those listed below must provide a phot ID at the time of pick up. Contact the summer camp director to make changes to this information.


Please enter the last name for your authorized pick up.


Please enter cell phone number for authorized pick up (xxx-xxx-xxxx).


Please enter home phone number for authorized pick up (xxx-xxx-xxxx).


Please enter relationship between authorized pick up and the child.


Children will only be released to those listed on this form unless notified in writing. Those listed below must provide a phot ID at the time of pick up. Contact the summer camp director to make changes to this information.


Please enter the last name for your authorized pick up.


Please enter the cell phone number for your authorized pick up (xxx-xxx-xxxx).


Please enter the home phone number for your authorized pick up (xxx-xxx-xxxx).


Please enter relationship between authorized pick up and the child.


Children will only be released to those listed on this form unless notified in writing. Those listed below must provide a phot ID at the time of pick up. Contact the summer camp director to make changes to this information.


Please enter the last name for your authorized pick up.


Please enter the cell phone number for your authorized pick up (xxx-xxx-xxxx).


Please enter the home phone number for your authorized pick up (xxx-xxx-xxxx).


Please enter the relationship of your authorized pick up and the child.





Includes all 8 weeks of Day Camp. You may select one week of vacation at no charge and still qualify for the full summer pricing.


You select weekly programs from 1 - 7 weeks (a la carte).


7:00am-8:00am Monday - Friday


4:30pm-6:00pm Monday-Friday





Select your program options.


Select your program options.


Select your program options.


Select your program options.


Select your program options.


Select your program options.


Select your program options.


Select your program options.





Please enter your child's doctor's first name.


Please enter your child's doctor's last name.


Please enter your child's doctor's phone number.


Please enter your child's doctor's address.


Check any conditions your child has experienced.


Check any conditions your child has experienced.


Check any conditions your child has experienced.


Check any conditions your child has experienced.


Check any conditions your child has experienced.


Check any conditions your child has experienced.


Check any conditions your child has experienced.


Please list any non-food allergies below.


If your child has food allergies or dietary restrictions, please include a statement from a medical professional (required). The statement can be uploaded below.


Please upload a statement from your child's doctor if food or milk allergies are a concern.


My child carries an epi-pen or inhaler with them.


My child must have an epi-pen or inhaler available to them at all times.


Please provide symptoms and/or special instructions for any condition marked above. (additional documentation may be attached using the file upload button above).


Does your child take medication on a regular basis?


If yes, what kind?


Fears the camp facilitators should be aware of?


If you answered "Yes" above, please explain the specifics about the condition.


An event in your child’s life that may be particularly upsetting?


If you answered "Yes" above, please explain the specifics about the condition.


Social or emotional characteristics you would like to note?


If you answered "Yes" above, please explain the specifics about the condition.


Other conditions requiring special care or additional information you feel would be helpful. (Additional pages may be attached if necessary using the file upload button above or explain in the space provided below.)







A copy of current immunizations for my child is provided with this form (required for enrollment). You may use the upload file button above to electronically submit your child's shot record.


Staff members may apply sunscreen to my child as needed. I understand that I am responsible for providing the sunscreen for my child.


Staff members may apply bug spray to my child as needed. I understand that I am responsible for providing the bug spray for my child.


I understand that for any medication to be administered to my child (over the counter or prescription), a medication form must be on file with the camp director.





My child has permission to participate in swimming activities.


My child has permission to participate in off-site field trips.


My child has permission to participate in photographs or video taken for publicity purposes.





I will notify the staff of any changes in my child's registration information.


I consent to my child's participation in the Messiah summer program and assume the risks involved. I attest and verify that I have knowledge of the risks involved in program activities and I give my child authorization to participate in such activities.


I have reviewed the Code of Conduct and Behavior Management Policy with my child/ren.


In the event that I cannot be reached to make arrangements for emergency medical attention at the time of illness or accident, l hereby authorize the staff of Messiah Lutheran Church and School Summer Camp to take my child to the nearest facility for medical attention.


I understand that it is my responsibility that my child is signed in upon arrival to the program, and signed out before leaving each day.


I understand that I cannot leave my child at the program site unless a staff member is there to receive and supervise my child. There must be an exchange of responsibility from an authorized individual to a staff member.


I understand that state law mandates the Messiah Lutheran Church and School Summer Camp to report any suspected cases of child abuse or neglect to the appropriate authorities for investigation.


I understand that I am responsible for all of the information in the Parent Handbook. A copy of the Parent Handbook is available online at messaihlutheranschool.com or I can request a printed copy from Messiah Lutheran Church and School Summer Day Camp.


By electronic signature and of free will l do hereby agree to indemnify and hold harmless the Messiah Lutheran Church and School Summer Day Camp for any and all claims or demands, cost of expense arising out of any injury or damage sustained by me or any party I am responsible for.


I understand that even when every reasonable precaution is taken, accidents can sometimes happen. Therefore, in exchange for allowing my child to participate in the summer program programs, I understand and expressly acknowledge that I, for myself and for anyone entitled to act on my behalf, waive and release Messiah Lutheran Church and School Summer Camp, it’s sponsors, representatives and successors from all claims or liabilities of any kind arising out of my child's participation in activities at or sponsored by Messiah Lutheran Church and School Summer Day Camp. I further agree to indemnify and save harmless Messiah Lutheran Church and School Summer Day Camp from any claims or demands arising out of such injuries or losses. I understand that this release includes any claims based on negligence, action or inaction of the Messiah Lutheran Church and School, its staff, directors, members and guests.





Acceptable payment forms are: cash, personal check, money order or credit card (subject to a 3% service charge).


To secure your child's seat, a $10 per week non-refundable deposit is due at the time of registration.


Payment in full must be received the Wednesday before the week your child is attending.


No adjustments in the weekly fee will be made for partially attended weeks, when care Is not provided due to holidays that the Summer Day Camp is closed or inclement weather days.


Refunds are typically not given. A Refund Request may be presented to the camp director; all refunds are at the discretion of the camp director.


If your payment is returned for insufficient funds (NSF), your payment along with an NSF service fee of $25.00 will be collected. A $10 late fee will be assessed on payments not made by the deadline.


A late pick up fee of $1.00 per minute will be assessed for each minute after 6:00pm that your child remains in our care. This fee will be added to the following week’s payment and must be remitted before your child is allowed to attend camp unless other arrangements have been made with the camp director.



I have read and understand the statements regarding Messiah Lutheran Church and School Summer Day Camp and agree to comply with its policies and procedures.

I further acknowledge that this application has been completed with as much accuracy as possible.

By printing my first and last name below, I am signing this form electronically with the same certification and weight that my written signature provides.



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