Faith United Methodist Church
July 20, 2013 9:00 AM – 12:00 Noon For Children Age 3 (by June 1, 2013), through 5 (Entering Kindergarten)
Mission To provide a fun, educational and age appropriate ministry for children ages 3 • 5 years; to connect young children and their parents to the church; to provide an opportunity for young children to interact with one another; to share the Good News of Christ with young children.
Registration Please complete the enclosed registration form and send the form and $25 fee to: Faith United Methodist Church c/o: Keiki Camp Registrar 2115 West 182nd Street Torrance, CA 90504 Checks should be made payable to: Faith United Methodist Church and earmarked Keiki Camp
Cost: $25 per Camper
Deadline: June 23, 2013
Registration will open at 8:45 a.m. on Saturday, July 20th. Please bring a change of clothes for your child. If your child has food allergies, please provide an appropriate snack.
Faith United Methodist Church
Keiki Camp
July 20, 2013
Registration Form Camper #1 First Name Last Name Toilet-‐Trained? Gender Birthdate *T-‐Shirt Size T-Shirt Size **Allergies/ Medication -‐ Please note any physical disabilities, allergies to medication, foods, etc. or medical prescriptions your child has or is in need of taking.
Camper #2 First Name Last Name Toilet-‐Trained? Size Gender Birthdate *T-‐Shirt Size T-Shirt **Allergies/ Medication -‐ Please note any physical disabilities, allergies to medication, foods, etc. or medical prescriptions your child has or is in need of taking.
*Youth sizes are listed: XS (2-‐4) S (6-‐8) M(10-‐12) L(14-‐16) CAMP PHOTO: Please mark your choice ______one picture per registered child OR Parent/Legal Guardian Information #1
First Name Address Zip Email
Last Name Home Phone
______one picture per family
Relationship City Alt Phone T-‐Shirt Size (if attending)
Parent/Legal Guardian Information #2
First Name Address Zip Email
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Last Name Home Phone
Relationship City Alt Phone T-‐Shirt Size (if attending)
Keiki Camp: July 20, 2013
Faith United Methodist Church
HEALTH FORM for Keiki Camp 2013 (please print clearly…)
Medical Insurance Coverage Medical Insurance Provider
Emergency Contacts First Name Relationship
Subscriber or Policy Number
Last Name Phone Number
Alt Number
Last Name Phone Number
Alt Number
First Name Relationship
LIABILITY RELEASE (Please sign after printing)
As the parent or guardian of the above named, I hereby grant permission for attendance as well as authorize Faith United Methodist Church to make any necessary decisions in case of emergency. I also hereby give permission to a physician selected by Faith United Methodist Church to hospitalize, secure proper treatment for, order injection anesthesia or surgery, for the above named, and will be responsible for any expenses incurred, including transportation back home if necessary for my child.
In no event will the Faith United Methodist Church, its staff, leaders or agents be held liable for any first aid rendered or treatment, drugs or medicines, or surgical procedures performed pursuant to this consent. In the event of an emergency, every effort will be made to contact the parent or guardian before any medical service is rendered aside from general first aid. Copies of this form may be made by Faith United Methodist Church will be considered as original.
Parent/ Guardian Name
Rev.042412
Parent/Guardian Signature
Date
Faith United Methodist Church
Keiki Camp: July 20, 2013
HEALTH FORM for Keiki Camp 2013
I request that my child(ren),
Keiki Camp 2013 Liability Waiver and Release Form ____________________________ ____________________________ ____________________________ ____________________________
be permitted to attend Faith United Methodist Church’s annual Keiki Camp. As the parent/legal guardian of the child named above, I accept general liability for my child’s participation, activities, and field trips throughout Faith United Methodist Church’s Keiki Camp and agree to indemnify and hold harmless Faith United Methodist Church, its employees, board of directors, officers, agents, and volunteers from any and all claims and liability for personal injury , death, or property damage as a result of my child’s participation in all of Keiki Camp activities and field trips. I intend this to be binding for myself, my child, my heirs, and executors, administrators and assigns. By my signature below, I acknowledge that I have carefully read this liability Waiver and Release and fully understand its contents. _____________________________________ _________________________________ ____________ Parent/Guardian’s Name (print) Parent/Guardian’s Signature Date 2115 West 182nd Street *TORRANCE, CALIFORNIA* 90504 PHONE: 310-‐217-‐7000 * FAX: 310-‐217-‐0571 EMAIL:
[email protected] Rev.042412
Faith United Methodist Church Keiki Camp
Photo Consent Form Keiki Camper’s Name(s)_____________________________________________ I do give consent for the taking of and using this child’s/children photograph for the purpose(s) here stated and with the conditions here noted: • I understand that the photographs taken will be used exclusively by Faith United Methodist Church; •
I understand neither I, nor the child, will receive payment for the taking of or using of the photos;
•
I understand that Faith United Methodist Church will not sell any of the materials in which these photos are used;
•
The photos taken will be used for newsletters, registration materials, flyers, slideshow presentations or other publications for exclusive use by Faith United Methodist Church;
•
If requested, Faith United Methodist Church will provide me with a copy of the publications so that I may see how the photos are used.
Signature____________________________________ Date_____________________________________ Name_______________________________________
Relationship to Child_________________________
Address_____________________________________ City___________________________________
Rev.042412
Zip Code__________________
