June 22 – 25, 2015 Please Type or Print Student Name M F

June 22 – 25, 2015
Please Type or Print
Student Name M
F
Age
Grade in Fall
Parent/Guardian
Preferred Phone Work Phone Email
Emergency ContactPhone Work
Relation to student
Dietary Needs/Concerns
Food allergies/medications
Medications taken during the day
Permission to walk to Freeway Park for recreation crossing 6th Ave. with supervision: Yes
Permission to photograph:
Music Lessons:
Yes
School
No
No
Private
Instrument #Years of lessons
Student’s special interests and gifts
Are you registering a sibling?
If so, what name?
How did you hear about the camp?
T-Shirt Size (all youth sizes) XS (2-4)
S (6-8)
M (10-12)
L (14-16)
Tuition Paid
Scholarship Received
Total
Parent Signature
Date Submitted
Questions?
Call Rosemary Hashimoto: 206.290.0502 or Plymouth Church: 206.622.4865
info@PlymouthChurchSeattle.org
XL (18-20)
Medical Authorization and Insurance Information
In order to insure that my son/daughter, is given
prompt medical attention, if it should ever be necessary, I authorize the staff of Plymouth Church, United Church of
Christ to consent to medical treatment, including x-rays or other diagnostic procedures or hospitalization, which may
be advised by any physician licensed to practice medicine in any state of the United States. It is understood that if time
and circumstances reasonably permit, the Plymouth Church UCC staff will try, but not be required, to communicate
with the undersigned prior to any such medical treatment or hospitalization.
Date Parent/Legal Guardian Signature
This is to let you know that my son/daughter has insurance that will cover medical treatment or hospitalization for
injuries sustained while participating in a Plymouth Church UCC activity under an insurance policy which is paid for
by me or my employer. The name of our accident or medical insurance company is:
Group # Policy # …………………………………………………………………………………………………………………………………
Permission Slip
I give permission for my son/daughter
to cross, with supervision, 6th Avenue at University
Street, Seattle, WA, to participate in recreation activities sponsored by Plymouth Congregational Church, United Church
of Christ through its staff and leaders. I agree to release and agree to hold harmless Plymouth Church UCC, its staff and
leaders, from any personal liability, not covered by insurance, arising from injury to my minor child.
Date Parent/Legal Guardian Signature