All Day Trinity Vacation Bible School 2023 Registration Form (Completed K-5th Grade)

Parent/Guardian Information

Name

Other Parent/Guardian Name

This address will receive a confirmation email

Other Parent/Guardian E-Mail

Your Phone

Other Parent/Guardian Phone

Address

Emergency Contact

Emergency Contact Name

Phone

Relationship to Family

Child Information

Child Name

Child Birthdate

Grade Completed 2022-2023

Gender

T-Shirt Size

Any Health Concerns/Allergies/Medications?

Early Bird Drop Off

To alleviate potential transportation issues for working parents, volunteers will be available by 7:45am to provide a gathering space for children whose parents need to drop them off early. If you need to take advantage of this service, please mark below. Thanks!

Do you need early bird drop off? Yes No

What time will you need to drop them off?

Parental Permission

By signing this form, I give my child permission to attend Day Camp, participate in all associated events both on-site and off, and authorize the Luther Crest staff & Trinity staff to seek necessary medical treatment in case of injury or illness. I understand Luther Crest assumes secondary insurance coverage; the child’s family assumes primary coverage. I also give Trinity Lutheran Church and Luther Crest permission to use any photograph/video of my child taken at VBS in the future promotion of Trinity or Luther Crest.

Electronic Signature

Date Completing Form

Anything else we should know or be aware of?

Luther Crest Bible Camp Health Form and Permission to Participate

Please complete the following health form. Campers MUST have a signed and completed health form to attend camp.

Camper Name

Insurance/Billing Information

In the event of an accident or injury requiring medical attention, your personal insurance will be considered PRIMARY CARRIER.

Company Name

Policy Number

Health History

Luther Crest uses this information to...
1) Provide health care with an informed background about your child;
2) Educate counseling staff about their respective camper needs;
3) Brief kitchen staff about dietary needs (onsite only)

Allergies/Food Restrictions - Check those which apply to this camper.

This camper has no known allergies. This camper has an allergy to a food (s), medication (s) and/or substance (s) Option

Please list food, medications and/or substances they are allergic to:

Do any of these allergies cause anaphylaxis?

Yes No

Describe the reaction(s) and what can be done for management:

General Health History: This camper has had:

Mononucleosis Mumps Chicken Pox Hay Fever Measles German Measles This camper has hearing within normal ranges This camper has vision within normal range.

This camper is free from illness, injury, or surgery which would affect participation:

Yes No

Chronic Health Concerns: Check all that pertain to this camper and provide information that would aid in providing supportive healthcare and a supportive environment.

This camper has no chronic concerns and is capable of full participation. This camper has following chronic concerns

This camper has the following chronic concern (s):

Asthma Diabetes Heart Defect/Disease Seizure Disorder Hypertension Frequent Colds Frequent Ear Infections Bleeding/Clotting Disorder Other

Please describe 'other' and additional information about checked item (s):

This camper has an emotional health concern

Yes No

This camper has a learning disability

Yes No

This camper has been diagnosed with Attention Deficit Disorder (ADD or ADHD)

Yes No

If yes was answered to anything in this section, please list below any special considerations that should be taken.

Medication: Please complete all required information. All medications MUST be in the original pharmacy containers and labeled appropriately. Campers MUST turn in all medications, vitamins and over-the-counter drugs to the Health Care Person upon arrival. For the safety of your child and other campers self-medicating is not allowed.

This camper does not take any medication This camper takes routine medication (please complete the following below) Option

Name of Medication:

Reason:

Dose:

Time (s) of Day:

If others, please list the needed information (name, reason, dose, time) below:

Immunizations: Please note month and year of the shots or the most recent booster.

DTP: Diphtheria, Tetanus, Pertussis

MMR: Measles, Mumps, Rubella

TD: Tetanus Booster

Others:

Name of Camper's Physician

Physician's Phone

Parent/Guardian Authorization of Health Care: This Health Form is complete and correct, and the person described has permission to engage in all camp activities except as noted by me and/or the examining physician. I give permission to th ecamp to: 1) provide ongoing health care, and 2) select medical personnel and to order X-rays or routine tests or treatment for the camper listed above. In the event that I cannot be reached in an EMERGENCY, I give permission to the physician selected by the Camp Director to hospitalize, secure proper treatment for, and to oder injection, anesthesia or surgery for my child named above. I understand that information about my child's health will be shared with the appropriate counseling, food service, or other Luther Crest staff. This form may be photocopied for use out of camp.

Parent/Guardian Permission to Participate: My child has permission to participate in all aspects of the Day Camp Program of Luther Crest Bible Camp and I agree that the camp or its personnel will not be held responsible for accidents arising from participation. I also give permission for any pictures or video taken of my child to be used for promotional purposes.

Electronic Signature of Parent/Guardian

Date

VBS Donation

Due to the generosity of a designated gift by the Sutter Family a fund has been created so every youth can attend VBS free of charge. If your family would like to make a donation to that fund to continue the gift for many years to come you are more than welcome to do so!

VBS Donation

Credit/Debit Card Number

Expiration Date/CVC

Name on Card Card Billing Address

All Day Trinity Vacation Bible School 2023 Registration Form (Completed K-5th Grade)

Description

Please Fix the Following