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					                        DIVE Camp Registration Form
                    Must Be Filled Out By Parent or Legal Guardian

Part I. Camper

First _________________Middle _____________ Last______________________

Grade (entering Fall 2010) _______           Birth date _____/_____/______

Age (as of June 1, 2010) ________

Street Address ______________________________________________

Town/City ___________________________ State ______ Zip code ___________

Camper’s Home Phone _______________________

Is there something you would like us to know about your child? Please let us know
here:
Part II. Parent/Guardian

Parent/Guardian #1
First_______________________________Last__________________________

Street Address ______________________________________________________

Town/City ____________________ State ___ Zip code ________

Home Phone ________________ Work phone _________________

Cell phone ______________________________

E-mail _________________________________


Parent/Guardian #2
First______________________________Last__________________________

Street Address ______________________________________________________

Town/City ____________________ State ___ Zip code ________

Home Phone ________________ Daytime phone _______________

Cell phone ______________________________

E-mail _________________________________


Camper lives with:
___________________________________________________________________
___________________________________________________________________
Part III. Emergency Contact and Security Information

Emergency Contact #1
First Name ___________________ Last Name ___________________

Home Phone ________________

Work Phone ______________

Cell Phone ___________________

Email _____________________________________

Relation to camper ______________________

Emergency Contact #2
First Name ___________________ Last Name ___________________

Home Phone _______________

Work Phone _______________

Cell Phone ___________________

Email _____________________________________

Relation to camper _____________________

Please list those people including parents/guardians who are permitted to pick up
your child:

1: ________________________________

2: ________________________________

3: ________________________________
Part IV. Medical Release Information

Insurance Information / Policy Number__________________________________

Name of Health Insurance Provider_______________________________

Family Physician_____________________________________________

Address_____________________________________________________________

Phone_______________________________________

Hospital Preference_____________________________________________

Please list any allergies/medical problems, including required maintenance,
medication (i.e. Diabetic, Asthma, Seizures).

Medical Diagnosis            Medication Dosage           Frequency of Dosage

1.

2.

3.


The purpose of the above listed information is to ensure that medical personnel
have details of any medical problem which may interfere with or alter treatment.
V. PAYMENT INFORMATION

In order to make DIVE Camp affordable for everyone, registration for the program
is only $20.00. This covers all activities, games, snacks and prizes.

This does not include the cost of the t-shirt (an additional $10.00).

Please make your check payable to Next Level Church and notate “DIVE Camp” on
the memo line.

Payment is due in full prior to the first day of DIVE Camp (July 16, 2010)


I have enclosed a check (#__________ ) in the amount of $_____________ for the
camp experience and $_____________ to cover the cost of the DIVE Camp T-shirt.


                                 Camper T-shirt Size

                                  Please Circle one:

                               Youth XS      S   M     L

                               Adult    S    M    L    XL
VI. Terms of Agreement

Next Level Church and/or DIVE Camp is not responsible for lost or damaged
personal property.

All scheduled events are subject to change.

I understand that there will be a certified lifeguard assigned specifically to Dive
Camp campers and staff at all times during the DIVE Camp experience.

I have been informed that all adult DIVE Camp volunteers have been fully
background checked and are experienced working with kids from a variety of
backgrounds.

I understand that no fees will be refunded unless a child is unable to participate
due to an accident or illness per physician orders. Campers’ photos and quotes
may be used for publicity purposes.

In case of an emergency, and if a family physician cannot be reached, I hereby
authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First
Responder, and/or Physician).

Next Level Church and/or DIVE Camp are not liable for any injury that may occur
during the DIVE Camp experience.


Please circle how you heard about DIVE Camp.
NLC, Newspaper, NLC Web-site, Word of Mouth, Other_____________________

Please sign, date and return this form to Next Level Church/Kid City Ministries.

Signature: ________________________________________________



Date: _________________________

				
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