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Youngs Chapel Level Up Summer Camp Registration

Child's Name

Child's Number

Gender

Gender

School Information

Date of Birth

Home Address

Age

Child lives with?

Person responsible for payment

Parent/ Guardian#1 -Contact Information

Phone Number

Email

Occupation

Employer

Parent/ Guardian # 2 - Contact Information

Phone Number

Email

Employer

Occupation

Emergency Contact Information #1 ‐ Alternate Pickup/ Release

Emergency Contact Information #2‐ Alternate Pickup/Release

Medical Release Information

Please list those people including in addition to parents / guardians who are permitted to pick up your child

Please list any medical problems including any required maintenance medication(i.e. Diabetic, Asthma, Seizures)

Medical problem

Required treatment

Should paramedic be called?

Should paramedic be called?

Required treatment

Should paramedic be called?

Should paramedic be called?

Required treatment

Should paramedic be called?

Should paramedic be called?

Is your child presently being treated for an injury or sickness or taken any form of medication for any reason? (i.e. Diabetes, Asthma, Seizures)

Is your child presently being treated for an injury or sickness or taken any form of medication for any reason? (i.e. Diabetes, Asthma, Seizures)

If yes, explain

Is your child allergic to any type of food or medication?

Is your child allergic to any type of food or medication?

If yes, explain

Does your child required a special diet?

Does your child required a special diet?

If yes, explain

Terms of agreement

Photo Release
I hereby give permission for my child to be photographed during the Youngs Chapel Level Up Summer Camp. I understand the photos will be used to keep a journal of activities to share during PowerPoint presentations and or reports and for promotional purposes including flyers, brochures, newspapers and on the internet. I understand that although my child's photographed maybe use for advertising, his or her identity will not be disclosed, I do not expect compensation and that all photos are property of Youngs Chapel Level Up Summer Camp and it's affiliates.

Parent's/ Guardian's initials

Initials
The Young's Chapel level up summer camp and it's co-organizers are not responsible for lost or damage personal property. All schedule events are subject to change. Children's photos and quotes maybe use for a publicity purpose. In case of emergency and if a family physician cannot be reached, I hereby authorized my child to be treated by Certified Emergency Personnel( i.e. Emt, first responder, and physician)

Printed name of Parent/Guardian

Date

Parent / Guardian Signature

Signature

Participation Consent Form

Required
I, the undersigned, hereby release discharge, indemnify, hold harmless and defend Youngs Chapel A.M.E. Church, it's officers, employees and servants of any and all liability( claim, demands, losses, causes of action, suits, judgments) of any kind that I or my family may have against them. In the event of any medical emergency, I authorize and consent of Youngs Chapel A.M.E. Church to act on behalf of Medical Care deemed necessary for the participant.

Name of Participant

Parent / Guardian Signature

Signature

Camp tuition: Free camp Registration Fee: 20.00

Registration fee submission
Please mail checks or money orders( No Cash )
To: Youngs Chapel A.M.E. Church
7336 Carlisle Street Irmo, SC 29063
Zelle information search for youngschapel7@gmail.com

Please direct questions to

Mrs. Harriet Abraham Summer Camp Director
Email: youngschapelcamp@gmail.com
Phone: 803-563-8372