LOMO Day Camp 2021

* Required Fields

Camper Information

*First Name

*Last Name
*Address
*City
*State
*Zip
*Gender
*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:

1.
2.

 

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 

 Other:   

 

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