Hamptons UMC - Summer Camp

First Name

Last Name

Phone Number

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Relationship to child(ren)

How many children are you registering?

Child 1 Name

Gender

Date of Birth

Current School

Current Grade Level

Any Allergies?

If yes, Explain

Any Medication?

Please Explain

Child 2 Name

Child 2 Gender

Child 2 Date of Birth

Child 2 Current School

Child 2 Current Grade Level

Child 2 Any Allergies?

List Allergies

Child 2 Any Medication?

List Medication

Child 3 Name

Child 3 Gender

Child 3 Date of Birth

Child 3 Current School

Child 3 Current Grade Level

Child 3 Any Allergies?

If yes, Please Explain

Child 3 Any Medication?

If yes, Please Explain (Child 3)

Emergency Contacts

The first attempt will be made to contact participants parents/guardians. Emergency contacts listed below must be able to pick up the child(ren) in the event of an emergency

Emergency Contact #1

Contact 1 Name

Relationship to child

Cell Phone Number

Alternative Number

Is the above person authorized to pick up the child(ren) at the end of the day in the event of an emergency?

Emergency Contact #2

Contact 2 Name

Relationship

Contact Cell Phone Number

Contact Alternative Number

Does the above person authorized to pick up the child(ren) at the end of the day in the event of an emergency?

Authorized Persons to pick up participant: Name/Phone Number

Signature

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