Registration Form Summer Camp

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SUMMER CAMP

REGISTRATION FORM

A. Name Sex DOB


Last First Middle

Please check one of the following:


Camp 1 May 29 – June 1 ________________
Camp 2 June 4 –June 7 _________________
Camp 3 June 11 – June 14 _________________

B. Registering Adult Home Phone

Address _

Email Address Cell Phone

Social Security # Relationship to Child

Place of Employment Work Phone

C. Other Adult in Home

Social Security # Relationship to Child

Place of Employment Work Phone

D. List all other household members

E. Child’s Physician Phone

F. Name and phone # of person(s) to be contacted in case of emergency when you cannot be reached.
Please do not list anyone who is working or lives out of town.

1. _
Name Phone Relationship to Child
2. _
Name Phone Relationship to Child
G. Name and phone # of person(s) authorized to pick up your child from school.

1.
Name Phone Relationship to Child
2.
Name Phone Relationship to Child

521 Providence Road, Chesapeake, VA 23325, 420-4720, glds@gracelutheranchesapeake.org


H. Does your child take any medications regularly? If so, which ones

List all allergies

I. Please tell us a little something about your child.


Words used for bathroom, special likes or dislikes, any unusual habits and anything else we should know to
help him/her feel at ease.

Are there any special difficulties such as allergies, physical handicaps or any condition that could affect
your child in school?

Is your child right or left-handed?

What are your child’s favorite activities?

J. Circle the proper choice:


1. Number of different children your child plays with regularly: Over 10 5 - 10 Less

2. Child controls his anger: At all times Fairly Well Not at all

3. Child is able to dress and undress: Completely alone With help Not at all

4. Child’s muscular coordination: Excellent Good Fair Poor

5. Child’s language ability: Excellent Good Fair Poor

K. Admission Policy

No discrimination in admission or in determination of enrollment will be made for race, creed,


color, sex, national or ethnic origin.
In the event of a physical handicap or chronic illness, admission to GraceLutheranDay School
will be predicated by the following: 1. Advice by the child’s doctor. 2. The safety and ability of
the child to participate in activities . 3. Staff capabilities. In these instances, the decision for
admission will be made by the School Board in consultation with the Director. Other
considerations are set by local and state regulations and the School Board as to the number of
students in each class.
Prior to admission, the child and a parent/guardian must visit the preschool and meet with the
director and/or the teacher.

L. Parent Authorization

My child has permission to participate in all school activities except as noted by me.

In the event I cannot be reached, I give my permission to secure emergency medical treatment for
my child .

Parent Signature Date

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