Trinity Evangelical Lutheran Church: Home: 2010 PDO camp registration

* Required

Errors

Email Address *

This registration is for dates: *

June 21 -23 - 25

July 12 - 14 - 16

August 2 - 4 - 6

CHILD"S NAME

First Name *

Last Name *

HOME PHONE *
( ) - ext.

MOBILE PHONE
( ) - ext.

FATHER"S NAME

First Name *

Last Name *

MOTHER"S NAME

First Name *

Last Name *

EMERGENCY CONTACTS

Give two names and phone numbers *

I UNDERSTAND THAT IN AN EMERGENCY I WILL BE CONTACTED IMMEDIATELY. I WILL TAKE APPROPRIATE ACTION FOR MY CHILD. I WILL ACCEPT FINANCIAL RESPONSIBILITY FOR THE CHARGES ASSOCIATED WITH THIS ACTION. IF I CANNOT BE REACHED TO MAKE NECESSARY ARRANGEMENTS OR IN A CRITICAL EMERGENCY REQUIRING IMMEDIATE CARE, I HEREBY AUTHORIZE TRINITY LUTHERAN STAFF TO CALL 911 AND ADMINISTER FIRST AID. I HEREBY AUTHORIZE TRINITY LUTHERAN TO CONTACT THE DOCTOR/HOSPITAL LISTED BELOW:

Doctor's Name and phone number *

Hospital Name and phone number

BY SUBMITTING THIS FORM, I HAVE ACCEPTED THE CONDITIONS LISTED ABOVE. NAME OF PERSON SUBMITTING: *

How did you learn about us?

Friend

Neighbor

Webster-Kirkwood Times

Church Signage

Doorhanger

I'm a Trinity member

Other (please specify)