Child's Name (required)

Child's Nickname (optional)

Birth Date (enter: mm/dd/yyyy)

Sex (required)
malefemale

Grade Child is Entering (required)
K1st2nd3rd4th5th6th

Home Address (required)

Home Phone Number (required)

Mother's Name (required)

Address (if different)

Mother's Cell (required)

Email (required)

Place & Phone# of Employment (required)

Father's Name (required)

Address (if different)

Father's Cell (required)

Place & Phone # of Employment (required)

PICK UP IMFORMATION: THE FOLLOWING PEOPLE HAVE PERMISSION TO PICK UP MY CHILD:

Name, Relationship & Phone#

Name, Relationship & Phone#

IN CASE OF EMERGENCY AND PARENTS CANNOT BE REACHED, THE FOLLOWING PERSON(S) SHOULD BE CONTACTED:

Name, Relationship & Phone# (required)

Medications or Allergies (food, organics, insects, animals)?

Child's Physician & Phone

Does Your Child Have Health Problems?
yesno

If "yes" Please Explain

Any Foods Your Child Cannot Eat?

Any Vision, Hearing or Speech Problems?

Helpful Info About Your Child (special interests, etc.)

Name & Age of Siblings

Was The Child Born Premature
yesno

If "Yes" How Many Weeks?

Hospitalized Within Last 3 Years?
yesno

If "Yes" Please Explain

As Parent and/or guardian, I do herewith authorize treatment by a qualified and licensed medical physician in case of a medical emergency. This authority is granted only after reasonable effort has been made to reach me.

Parent/Guardian E-Signature (required)

Date Signed (enter: mm/dd/yyyy)

PHOTOGRAPHY /VIDEO PERMISSION:

As the parent/guardian, I give permission for any video images or photographs that may be taken of the subject of this release during Summer Journey events to be used, distributed, or shown as Community Presbyterian Church sees fit.

Parent/Guardian E-Signature (required)

Date Signed (enter: mm/dd/yyyy)

ROSTER PERMISSION:

As the parent/guardian, I give permission for my e-mail address to be used to send out parent e-mails regarding upcoming events at Summer Journey and/or Community Presbyterian Church.

Parent/Guardian E-Signature (required)

Date Signed (enter: mm/dd/yyyy)

WEEK CHOICES: (You can select more than one option. Field trips shown in parenthesis.)
Week 1 (June 21-25) Explore the Sea (Wed 6/23 - Space Walk Waterslide on campus)Week 2 (June 28 - July 2) Super Science Week (Wed 6/30 - Orlando Science Center Virtual Experience on campus)Week 3 (July 5-9) Sports Week (Wed 7/7 - Putting Edge @ Artegon)Week 4 (July 12-16) Messy Week (Wed 7/14 - Space Walk Waterslide on campus)Week 5 (July 19 - 24) Monkeyin’ Around (Wed 7/21 – Monkey Joe’s @ Pointe Orlando)Week 6 (July 26-31) Junior Picasso Week (Mon July 26 – Clay Sculpture, Wed July 28 – Canvas Paining)Week 7 (Aug 2-6) Sweet Summer (Campers will enjoy Water Fun all week long! )