Saint Michael and All Angels Episcopal Church

Summer Arts Camp Application

Camper's Information

Camper's Name(Required)

First Last

Camper's Date of Birth(Required)

Camper's School(Required)

Camper's Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent/Guardian Information

Parent/Guardian Name(Required)

First Last

Parent/Guardian Relation to Camper(Required)

Parent/Guardian Preferred Phone(Required)

Parent/Guardian Email(Required)

Parent/Guardian Alternate Phone

Additional Parent/Guardian Name

First Last

Additional Parent/Guardian Preferred Phone

Additional Parent/Guardian Email

Emergency Contact

Emergency Contact Name(Required)

First Last

Emergency Contact Phone(Required)

Medical Information (if applicable)

In case of medical emergency, I understand that effort will be made to contact me. If I cannot be reached, I hereby give permission to the physician selected by the adult leader to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child named above.(Required)

I agree

Parent/Guardian Medical Authorization

Medical Insurance Company Name

Medical Insurance Policy Number

Medical Insurance Member ID #

Family Doctor / Clinic Name

Family Doctor / Clinic Phone

Consents

The above camper has my permission to attend activities with leaders from St. Michael and All Angels Church. I understand activities will be under the supervision of one or more adult leaders approved by the church. I waive any claim against the church and its approved leaders.(Required)

I agree

Parent/Guardian Consent

I have read and understand that my child will be expected to follow the ARTS camp rules and behavior guidelines. Violators will be warned: further problems will result in dismissal from camp without reimbursement.(Required)

I agree

Parent/Guardian Consent

I grant permission to St. Michael’s to share photographs and video taken of my child while at Arts Camp for any lawful purpose including publication, promotion, illustration, advertising, trade, or historical archive in any manner.(Required)

I agree

I do not agree

Parent/Guardian Consent

Does your child have any needs we should be aware of, so that we may provide him/her with the best possible camp experience? Please explain.(Required)