Registration Form - The Baptist Church of West Chester > Home Page

Registration Form
Jesus & You: 10 ‘til 2
July 21-25, 2008

Fill in the information below or download an application by clicking here to mail in. Deadline for application is May 15, 2008.

*Required Fields
Child’s Information:
Name:	*
Date of Birth (mm/dd/yy):	*
Current Grade Level:	*
**NOTE: 3 & 4 year old campers will attend from 10am-1pm. We’ll feed them lunch and then send them home for naptime.
Is this your child’s first time attending camp at The Baptist Church of West Chester?	*
Will your child be participating in the Closing Ceremonies on Friday July 25 @ 7pm?	*
What size T-shirt does your child wear?	*
Does your child/family regularly attend church? If yes, where? Name of church:

Parent’s Information:
Name:	*
Street Address:	*
City:	*
State:	*
Zip code:	*
Phone:	*
Cell Phone:	*
Email:	*
Insurance Company Name:	*
Insurance Group #:	*
Insurance # required to complete registration.

Emergency Contact:
Who should we contact if you are not available in case of emergency?
Emergency Contact Name:	*
Emergency Contact Phone:	*
Relationship to child (aunt, neighbor, etc.):	*

Special Concerns:
Does your child have any allergies to food or medication? If yes, please list:


Does your child have any special needs we need to be aware of, such as an IEP, social issues, medical needs, etc.? If yes, please list:

PARENTAL WAIVER: By submitting this form I understand that I am releasing the Baptist Church of West Chester and the volunteer teachers and coordinators of any responsibility or any liability incurred by my child during the day camp. In the case of a medical emergency, I give authorization to the camp coordinators to seek medical attention.