Marietta Christian Church Summer Camp

(Recreational and Educational Program)

Marietta Christian Church
285 Victory Drive S. E.
Marietta, Georgia 30060
678-308-0855
Registration Form
Additional siblings require another form (1 child per form)
Child's Name__________________________________________ M/F (Circle)
Address____________________________________________________________
City____________________________________ State_______ Zip__________
Home Phone#________________________________________________________
E-mail Address_____________________________________________________
Age____ Date of Birth________ Grade _____
Parents'/Guardians' Names__________________________________________
Other numbers where parents/guardians may be reached (work, cell,
etc.)
___________________________________________________________________
___________________________________________________________________
ALTERNATIVE CONTACT - for emergency and you cannot be
contacted:
Name/Relationship__________________________________________________
Phone Number(s)____________________________________________________
MEDICAL INFORMATION
Dates of last immunizations: please provide a copy of immunization
records for
MMR, DPT, Polio, Chicken Pox, Tetanus, Hep B, and HIB
ALLERGIES:
(Please write "none" if no allergies)____________________
___________________________________________________________________
___________________________________________________________________
MEDICATIONS List below, with doses and times
(Please write "none" if child does not take any medication.)
___________________________________________________________________
___________________________________________________________________

MEDICAL CONDITIONS (including A.D.D. and A.D.H.D.)

(Please write "none" if no medical conditions exist.)
______________________________________________________________________
Physician name and
number________________________________________________
Insurance name and policy number
__________________________________________
Medical Treatment Consent
I, the undersigned, give permission for staff members to obtain and
authorize medical care for my child at any hospital, emergency
medical center or any other health facility; by any medical doctor,
osteopath, nurse, surgeon or any other medical practitioner. I also
agree to be responsible for the expenses of any medical care required,
and damages suffered by myself as a result of the medical treatment
Please Print Name: _________________________________________________
Please Sign Name: __________________________________________________
Date: __________________________________
Release of Damages and Liability
I, the undersigned, hereby release the facility and staff from any and
all damages suffered as a result of attending the camp unless it is the
direct and indisputable fault of negligence on the part of the staff
which must be proven and witnessed by someone of credibility and
willing to give testimony in a court of law. Furthermore, the will bear no
liability for injury resulting in attendance and use of said facility.
Please Print Name: _________________________________________________
Please Sign Name: __________________________________________________
Date: __________________________________
Payment Plan
Weekly (4-5 days), Daily (1-3 days), Hourly (1-3 hours)
FEE:
$85.00 per week; $20 per day, $5.50 per hour
More than one sibling 10% off the original price
Weekly fees are due by Monday in the form of a Money Order, Cash or
Cashiers Check