LOMO Day Camp 2021

* Required Fields

Camper Information

*First Name

*Last Name
*Grade Completed
* Birthdate
T-shirt Size
Home Church


Parent/Guardian Information

* Name(s):
* Phone Number:
 Phone Number:
* Email:


Additional Emergency Contact  (If parents/guardians are unavailable)

* Name * Phone


During Day Camp, how will your child come and leave from the day camp site?  


The following person(s) is/are permitted to pick up my child from Day Camp:



DO NOT release my child to the following:   


Health & Permission Form

List any disability or recurring illness: 

Note any activites to be limited:

Specify any dietary concerns:

Include current medications / treatments:

Note all allergies:

 Bee stings     Aspirin     Pencillin     Peanuts/Nuts 



All medications sent to camp must be in the original containers and give to the Christian Education Coordinator



Release: I hereby give permission for the camper, previously named, to participate in all day camp activities and off-site field trips, except as previously noted. I also consent to the use of any photograph or video recordings of my child or family in future LOMO or ELCA publications. 

I understand that every effort will be made to contact me if my child needs emergency medical-surgical treatment. But if it is important to do so, I hereby give my permission to the physician selected by the Camp Staff to secure property treatment, to hospitalize, to order injection, anesthesia, x-ray or surgery for my child as named above. I further authorize the Church Coordinator, or their designee, to administer over the counter drugs and mediations as needed.

* Date
* Signature




Evangelical Lutheran Church in America
Northwestern Ohio Synod Stephen Ministries