Gender *
Select an option Male Female
Grade (Fall 2021) *
Select an option Kindergarten First Second Third Fourth Fifth Sixth
Age (As/of June 21, 2021) *
Select an option 5 6 7 8 9 10 11 12 13
Camper 2 Gender
Select an option Male Female
Camper 2 Grade (Fall 2021)
Select an option Kindergarten First Second Third Fourth Fifth Sixth
Camper 2 Age (as/of June 21, 2021)
Select an option 5 6 7 8 9 10 11 12 13
Camper 3 Gender
Select an option Male Female
Camper 3 Grade (Fall 2021)
Select an option Kindergarten First Second Third Fourth Fifth Sixth
Camper 3 Age (as/of June 21, 2021)
Select an option 5 6 7 8 9 10 11 12 13
Camper 4 Gender
Select an option Male Female
Camper 4 Grade (Fall 2021)
Select an option Kindergarten First Second Third Fourth Fifth Sixth
Camper 4 Age (as.of June 21, 2021)
Select an option 5 6 7 8 9 10 11 12 13
Alternate Pick Up - Please list the names of ALL ADULTS who are authorized to pick up your child *
Please list any medical problems, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures).
Medical Problem and Required Treatment
Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason? *
Select an option Yes No
Is your child allergic to any type of food or medication? *
Select an option Yes No
If you answered "Yes" to any of the questions above, please describe:
The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere
with or alter treatment.
I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a
medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further
endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.
Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, xray
examination and
immunizations for the named camper. In the event of an emergency arising out of serious illness, the need for major surgery, or significant
accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way
possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to the First
Baptist Church Day Camp and its affiliates including Directors, Staff, and Team Parents to provide the needed emergency treatment prior
to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is
authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for
the protection of life and limb of the named minor child, in my absence.
I understand that the First Baptist Church Day Camp will not be responsible for the medical expenses incurred, but that such
expenses will be my responsibility as parent/guardian.
I hereby give permission for the transportation of my child for official First Baptist Church Day Camp activities by modes of
transportation agreed to by the camp organizers.
I hereby give permission for my child to be photographed during the First Baptist Church Day Camp . I understand the photos will be
used to keep a journal of activities, to share during power point presentations and/or reports to our donors and for promotional purposes
including flyers, brochures, newspaper and on the internet. I understand that although my child’s photograph may be used for advertising,
his or her identity will not be disclosed, I do not expect compensation and that all photos are the property of First Baptist Church Day
Camp and its affiliates.
Tuition Payment - $50 to help cover activities and transportation cost. *
Select an option I will make an online payment of $50.00 following this registration using the provided online payment button I will pay $50.00 at camper registration on Monday June 21st 2021 I would like to receive a scholarship for my child
By entering my name below, I acknowledge that the above information is true and accurate to the best of my knowledge, and authorize my child to participate in the Superhero University Day Camp.