Registration Fee: $40 per child
Name ______________________
Date of Birth ________________ Grade Completed_________ Age________
Parent/Guardian _____________ Address ________________________________
City __________ State __________ Postal Code ______________ Home Phone _____________
Cell Phone _________________ Email_________________
Emergency Contact Name____________ Phone number_________________
Special Needs/Allergies __________________________________
Is there a special friend your child would like to be with ____________________
Class/Crew assignment (assigned by Church) __________________
Vacation Bible Camp
Waiver and Media Release
When: July 11th – 15th, with showcase July 17th- 10am service
Where: Mt. Sinai Congregational, UCC, 233 North Country Road, MT. Sinai NY 11766
Questions: Caroline LaVopa, 631-473-1582
Please fill out all information requested below (one per youth):
Registration/Emergency Medical Information
Participant Information:
Name: _____________________________________________________
Date of Birth:______________
Address:_________________________________________City:______________
St:________ Zip:______ Home Phone: ( ) ___________________ email address: ______________
Please list any medical conditions, injuries, or allergies: ________________________________________________________________________________
In Case of Emergency Contact:
Name: ______________________________________
Daytime Phone: ( ) ______________ Evening Phone: ( )_____________ Alternative Phone Contact: ( ) __________________ Relationship____________
Physician Information:
Physician’s Name: ____________________________________
Office Phone: ( ) _______________ Address:_________________________________________City:________________
St:_____Zip:______
Medical Release: In the event of an emergency, I authorize the administration of any first aid, transport, examination, diagnosis, and/or treatment that is deemed necessary by Mt. Sinai Congregational, UCC Church or any paramedic, nurse, physician, or dentist.
Parent/Guardian Signature_______________________________________________ Date___________
(REQUIRED if participant is under 18 OR is covered by parent’s insurance)
DISCLOSURE AND ACKNOWLEDGEMENT OF RISK
The program activities are designed to be within the capability of anyone who is in reasonably good health.
Prospective participants who are not in good health, who have pre-existing medical conditions, or who have questions about their current state of health should consult with their physician before participating.
Media Consent. I give my consent and permission for the taking of photographs and/or video of me (or my child) during the described programming and I waive and/or assign all rights (including copyright) in such media to Mt. Sinai Congregational, UCC. Mt. Sinai Congregational, as the sole owners of such media, shall have the exclusive right to control and determine the use, display, performance, reproduction and dissemination of any such photographs and/or videos. Please note, we will not identity any of the children by name.
Please circle one statement:
Yes I consent to above Media consent
No I do not consent.
The undersigned covenants that he or she will not sue Mt. Sinai Congregational, UCC Church or otherwise pursue any claims for any risks or injuries identified in this document or otherwise arising out of the programs. The undersigned agrees to indemnify Mt. Sinai Congregational, UCC Church, provide a defense, against any and all claims for any risks or injury arising out of, or in connection with, the programs.
Parent/Guardian Signature_____________________________________________ Date_________________
(Required if participant is under 18)
