Delavan Day Camp

at Faith Lutheran Church

June 11 - 14
9:00am-3:00pm

Completing Grades K-5
Free to Attend

Contact Gail Ottesen with Questions
bgott@bevcomm.net

Delavan Day Camp Registration

Camper Name

First Name

Last Name

Birthdate

YYYY

Grade Completed

Gender

Home Address

Parent/Guardian 1

First Name

Last Name

Day Time

(###)

###

####

Cell

(###)

###

####

Parent/Guardian 2

First Name

Last Name

Day Time

(###)

###

####

Cell

(###)

###

####

Camper lives with

Parent/Guardian 1

Parent/Guardian 2

Both Parents/Guardians

Other

Emergency Contact

First Name

Last Name

Relationship

Phone

(###)

###

####

Checkbox *

My child has permission to participate in all aspects of the Day Camp program. I hereby give my permission to the physician selected by the Congregational Coordinator or Good Earth Village Day Camp Coordinator to secure proper treatment, to hospitalize, to order injection, anesthesia, x-ray or surgery for my child as named above. Every effort will be made to contact me if my child needs emergency medical and/or surgical treatment. I understand that my insurance has primary coverage. I also give permission for pictures and video taken of my child to be used for promotional purposes.

Yes, I agree

No, I do not agree

Electronic Signature *

Electronic Signature

First Name

Last Name