Upcoming Events

See below for a Day Camp Registration form!

 

PINERY BAPTIST CHURCH

8751 Lakeshore Rd, Hwy 21, Northville

2019 DAY CAMP REGISTRATION FORM

Theme: “The Incredible Race”

 

August 12-16, 2019

 

Cost Per Child: $50.00

 

Children that have completed SK up to Grade 6

 

CHILD’S INFO:

 

Name:___________________________________________________   Birthdate:(Day/Month/Year)__________________     

Age:_____      Grade Completed: ______       T-Shirt Size: Youth Sm ______   Youth Med ______   Youth Lg ______

 

Allergies:         ____ Yes   _____ No (If yes, please describe)   

_________________________________________________________________________________________________________

Medicine(s):     ____ Yes    _____ No (If yes, please describe)   

 

_________________________________________________________________________________________________________

 

Special Needs: _____ Yes   _____ No (If yes, please describe)_________________________________________________________

 

PARENT/GUARDIAN INFO:

 

Names (please print): _____________________________________________  Email__________________________________

 

Address: (Street, City, Postal Code)

 

________________________________________________________________________________________________________

 

 

Phone (day)_____________________________________Cell/pager__________________________________________________

 

EMERGENCY CONTACT (if different from above):

 

Name _________________________________________  Relationship: _________________  Phone # __________________

 

Other Instructions, such as custody/pick up permission:

 

_________________________________________________________________________________________________________________

 

PARENT/GUARDIAN CONSENT:

 

I consent to have pictures of my child taken and used by Pinery Baptist Church   Yes___No ___

 

MEDICAL CONSENT/WAIVER:

 

Our program is possible through the efforts of volunteers.  Your child will be cared for as if he/she were our own child.  It is understood that caution will be taken by those persons in charge of a particular program to prevent injury, but complete freedom from injury cannot be guaranteed.  An incident report will be provided should an accident occur.  I hereby consent to let volunteers seek medical attention for my child if I cannot be reached and immediate attention is deemed necessary.  I hereby consent for my child to participate in this organized activity.  I understand that my child will be under the supervision of a designated church volunteer at all times on the stated dates and times.  As a parent or legal guardian, I remain fully responsible for the actions and conduct of my child including any legal responsibility, which may result.  In consideration of my child being allowed to participate in this event, I agree to indemnify and hold harmless Pinery Baptist Church, and its representatives, including volunteers, from any and all claims, including negligence, arising from or relating to my child’s participation in this event.  This indemnification and hold-harmless agreement does not apply to claims for intentional misconduct or gross negligence.

 

 

Parent/Guardian Name (Please Print) _______________________________________________

 

 

Parent/Guardian Signature: ________________________________________________  Date_____________________

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