Free To Be Me

2015
Evening Summer Camp
Saint Georges Episcopal Church Community Outreach Program
160 U Street, NW, WDC 20001
202-387-6421 (phone) / 202-387-9053 (fax)

Registration and Parental Consent Form

Registration is mandatory and closes on Monday, August 17th, the first day of the program.
It is important for children to attend each day so they can receive a complete experience, including participation in the
closing program on Friday, August 21st. Please complete and return this registration form to the church office as soon as
possible by dropping in church office mail slot next door to the church or by faxing.

Name of Child(ren) ____________________________________________ Age ____

____________________________________________

Age ____

____________________________________________

Age ____

Name of Parent/Guardian ________________________________________________

Address ________________________________________________________________
Phone #s: (home) ________________ (cell) ___________________
Emergency Contact Person: Name ___________________________ cell # _______________
[ ] I (Adult) agree to the following and direct my child to:
Cooperate with rules and instructions of St. Georges staff in charge of activities. If necessary, I give St. Georges
staff permission to use their judgment in obtaining medical services for any serious injury sustained by my child
during participation in these activities. I give permission to the physician assigned to render medical treatment
deemed necessary and appropriate by the physician. I understand that St. Georges has no insurance covering such
medical or hospital costs incurred and, therefore, any cost incurred for such treatment shall be my sole
responsibility.

[ ] My child is covered by accident/medical insurance

[ ] My child is NOT covered by accident/medical insurance

ALL PERSONS PARTICIPATING in the Free To Be Me Program are deemed to have waived all claims against
St. Georges Episcopal Church and its employees or representatives of the church and/or Diocese for injury,
accident, illness or death occurring as a result of participation in activities of the Free To Be Me Program.
Initialize _____

I give consent for the above child(ren) to attend this evening summer camp for:
Monday, August 17th through Friday, August 21st 2015, 4:00pm to 8:00pm
Parent/Guardian Signature _________________________________________

Date _____________