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SUMMER CAMP REGISTRATION

YOU CAN'T BEAT $260 FOR THE SUMMER!!

Summer Camp runs from July 8 - August 9, 2024

9:00AM - 3:00PM

Camp Fee: $52 per week (includes tshirt, trips, breakfast, lunch and snack)

Child First Name:

Child Middle Name:

Child Last Name:

Gender

Birthdate

Address 1:

Address 2:

City:

State:

Zip Code:

T-Shirt Size:

Child Age :

Child Allergies:

Is your child Special Needs?

Physician Name

Physician Phone Number

Insurance Provider:

Name of Insured

Insurance Policy Number

Are immunizations current?

Date of last Tetanus Shot (mm/dd/yyyy)

To the best of my knowledge, this child is healthy and fit for an active camp program.

The camper is currently experiencing or has recently had problems with:

Has your child been exposed to any communicable disease in the past 6 months? (If yes, please specify)

Previous hospitalizations/surgeries:

List any imitations of activities by physician's advice (i.e. swimming, hiking, etc.):

Free Text

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Parent 1/Guardian 1 First Name:

Parent 1/Guardian 1 Last Name:

Parent 1/Guardian 1 E-mail:

Home Phone:

Work Phone (include ext):

Mobile Phone:

Free Text

_________________________________________________________________________________________________________________________________________________________

Parent 2/Guardian 2 First Name:

Parent 2/Guardian 2 Last Name:

Parent 2/Guardian 2 E-mail :

Home Phone:

Work Phone (include ext):

Mobile Phone:

Free Text

_________________________________________________________________________________________________________________________________________________________

Emergency Contact:

Emergency Contact Relation to Child:

Emergency Contact Phone:

PERMISSIONS

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DISMISSAL

My child will walk home each day at 3:00p.m. (unless camp director is notified)

I will pick up my child or give permission for the person(s) listed below to pick up my child at/or before 3:00p.m.

DISMISSAL PERSON 1 (Name & Phone Number)

DISMISSAL PERSON 2 (Name & Phone Number)

I GIVE MY CHILD PERMISSION TO ATTEND FIELD TRIPS.

YES, I do

NO, I don't

PERMISSION and RELEASE (Please read and check off the boxes to accept the release statements below)

Publicity Release: I understand that from time to time the church may use photographs/video recordings of participants in Blessed Sacrament Summer Camp Enrichment for Kids! programs for public relations interest stories, articles, news and other marketing of Blessed Sacrament Church in the newspaper, on television, and the web site. I give permission for such photographs of my child to be used for marketing purposes. I give The Church of the Blessed Sacrament permission to audio, video, and photograph of this registering camper for the purposes of the camp’s public relations and promotions without compensation or approval rights (i.e. brochure mailings, highlight promotional videos, and photos for our website).

Medical Release: The health history is correct so far as I know, and the person described has permission to engage in all prescribed camp activities except as noted. In Case of Medical Emergency, if I cannot be contacted, I hereby give permission to a camp representative and the physician he/she selects to secure proper treatment, including: hospitalization, ordering injections, giving anesthesia, x-rays, routine tests, treatment, transporting of child, or performing operations as may be urgently necessary for this child and to release reports necessary for insurance purposes for my child noted above. I authorize Blessed Sacrament Church to obtain medical treatment for my child in an emergency or to take other necessary actions for my child’s safety and well-being. I release and agree to indemnify Blessed Sacrament Church from any liability to any person arising out of good faith decisions made by Blessed Sacrament Church pursuant to the provisions of this paragraph. This form may be copied for emergency purposes. I understand that every effort will be made to contact the camper's responsible parent or guardian. I further understand that if I do not have medical insurance that covers all costs, I will be responsible for such medical costs.

Transportation Release: I hereby give permission for my child, to participate in the transportation program and to travel on a school bus for field trips with the Blessed Sacrament Church Camp. I also give my permission for my child to be transported, if necessary, in emergency situations, as well as, when the camp needs to be evacuated for the safety of the children.

Liability Release: In consideration of being permitted to participate in any way in the activities at and to attend The Church of the Blessed Sacrament Summer Program, I, for myself, my child, my heirs, personal representatives or assigns, do hereby release wave, discharge, and covenant not to sue The Church of the Blessed Sacrament, its parent organization, its officers, employees, and agents, from liability from any and all claims including the negligence of The Church of the Blessed Sacrament, its parent organization, its officers, employees, and agents, resulting in personal injury, accidents or illnesses (including death), and property loss arising from, but not limited to the activities and attendance at The Church of the Blessed Sacrament Summer Program. I warrant that my child is physically fit and able to participate in all Camp Activities except those listed above. I also agree to INDEMNIFY AND HOLD HARMLESS the Church of the Blessed Sacrament, its parent organization, its officers, employees, and agents, from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney's fees, as a result of my child's attendance and involvement in any activities at The Church of the Blessed Sacrament Summer Program. Including any claim asserted by my child after he/she become an adult. I also acknowledge that I have read the above and understand that I am giving up substantial rights, including the right to sue. I acknowledge that I am signing freely and voluntarily, and intend by my signature to a complete and unconditional release of all liability to the greatest extent allowed by law.

PARENT SIGNATURE:

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About Us

We welcome you all to be part of our community.

QUICK LINKS

CONTACT

203-333-1202

pastor@blessedsacramentbpt.org

275 Union Ave, Bridgeport, CT, United States

Admin

Subscribe nowjsy

SUMMER CAMP REGISTRATION

** Camp Fee: $52 per week (includes tshirt, trips, breakfast, lunch and snack) **

About Us

We welcome you all to be part of our community.

QUICK LINKS

CONTACT

203-333-1202

pastor@blessedsacramentbpt.org

275 Union Ave, Bridgeport, CT, United States

Camp Fee: $52 per week (includes tshirt, trips, breakfast, lunch and snack)