Camp Shirts Please mark how many of each size. Youth S (6/8) ______ Youth M (10/12)____ Youth L (14/16)_____ Adult S___________ Adult M__________ Adult L___________ Adult XL__________ Shirts are $10.00 each, while supplies last.
Totus Tuus...Totally Yours June 5th—9th, 7:15-9:45 p.m.
Children Entering Seventh Grade through Twelfth Grade $25.00 Registration Fee (per child) with a $120.00 Family Max. (Family max. includes kids registered in Day Camp, the Jr/Sr High Program, and VBS!) Financial assistance is available, contact Martin Verstraete in the Parish Office (816-229-3378) for more information. Jr/Sr High Program registration will be limited to 90 kids or May 31, 2016. Registration should be turned in to the Parish Office. Have questions? Contact Amy Davis at 816-229-3378 ext. 314 or
[email protected].
Family Last Name___________________________ Email_______________________________________ Address__________________________________________ City_______________________ Zip_____________ Parent Name(s)________________________ Work/Cell Phone _________________(where you can be reached) Emergency Contact______________________________ Phone__________________ Date_______________ Parent Signature_________________________________________ (Signature of Child’s parent or guardian is required) Children in Family to Register: Name____________________________ Age___ Birth date___________ M/F Entering Grade______ Name____________________________ Age___ Birth date___________ M/F Entering Grade______ Name____________________________ Age___ Birth date___________ M/F Entering Grade______ Name____________________________ Age___ Birth date___________ M/F Entering Grade______ Food Allergies or other Medical Conditions __________________________________________________________ Family Doctor______________________________ Telephone______________________________________ Church you attend ______________________ How did you hear about Totus Tuus? _____________________
I give permission for my child/children to be photographed during Totus Tuus.
=========================================================================================== We are in need of several parents to help with check-in, serve and clean-up snacks, and supervise youth each night of the program. Please indicate below which nights you are able to help. Thanks! _____Sunday
_____Monday
_____Tuesday
_____Wednesday
_____Thursday
Name______________________ Phone# _______________ Email ___________________________________
=========================================================================================== AUTHORIZATION FOR EMERGENCY MEDICAL CARE
I understand that I will be notified at once in case of accident or illness to my child, and I will make arrangements for medical care of my child with the physician or hospital of my choice. If I cannot be reached to make necessary arrangements, or in a critical emergency requiring medical care, I hereby authorize St. John LaLande Parish to contact the following: FOR EMERGENCY MEDICAL TREATMENT, MY PREFERRED HOSPITAL IS: (Name & City) _________________________________________________________________________________________________________________ DOCTOR NAME & PHONE NUMBER: _________________________________________________________________________________ PRIMARY INSURANCE CARRIER & POLICY #: _________________________________________________________________________ PARENT’S SIGNATURE ___________________________________________________________
DATE ______________________
FOR OFFICE USE Registration Amount $____________ + T-Shirt Amount $______________ = Total Amount $___________
Paid: Cash___________ Check_____________ Check#____________ Date_________________
