DAY CAMP & CAMP – REGISTRATION 2013 Name Date of Birth

ALLERGIES Type of Reaction: Please mark which apply

Type of Allergy

Please circle

Describe/ Specify Allergen

Mild Moderate (Swelling or severe rash)

Severe (Difficulty breathing)

Food No Yes

Medication No Yes

Environmental (animal, plant, insect, etc.)

No Yes

Other No Yes

Please provide written description of treatment for allergies where needed.

Over-the-Counter Medications I, the parent or guardian of ___________________ give permission to Maureen Hagen or a designated adult leader to give the following medications (or their generic equivalents) to my child, in accordance with recommended package dosing for the specific indications below. __ Acetaminophen (Tylenol or generic) __ OTC Antacid (Tums) __ Ibuprofen (Advil or generic) __ Antibiotic Ointment __ Diphenhydramine (Benadryl) __ Sunscreen (without PABA, minimum SPF 30) __ Non-medicated cough drops __ Hydrocortisone

(Unchecked boxes mean camper MAY NOT received that medication.) Signature of parent/guardian: ___________________________ Date ________________

Does your child have any special needs (behavioral and/or physical) we should know about? Health Insurance Co.

Group No. Subscriber No. I hereby give informed and expressed consent for my child to take part in all camp activities under supervision, and agree that Camp Lutherwood, Gethsemane Lutheran Church, or Day Camp/VBS personnel will not be held responsible for accidents arising there. I authorize Maureen Hagen and/or Day Camp/VBS staff/volunteers to provide appropriate treatment to my child for injuries and/or illness. I understand the information on this form may be released to the appropriate medicate personnel in case of medical emergency. I also understand that failure to disclose medical or emotional issues in advance may lead to serious consequences while at Day Camp/VBS. Lastly, I verify that everything contained on this form is complete and accurate, to the best of my knowledge. I consent to the use of any photograph of my child in Lutherwood/Gethsemane publications. _______ Field Trip Permission: My child has my permission to participate in Day Camp activities away from Gethsemane Lutheran Church (which may include a visit to Mill Park or Ventura Park.) Parent/Guardian signature Date

GETHSEMANE LUTHERAN

DAY CAMP

& VBS

JULY 15-19, 2013

DAY CAMP (9:00-3:00; 11:45 on Friday) Campers are kids entering grades 1-6. Youth entering grades 7-12 are invited to apply as leaders or assistants. Registration: $25/camper* ($40 maximum per family). Includes healthy snacks and lunch. Please fill both sides of the registration form and submit to: Gethsemane Lutheran Church 11560 SE Market Street Portland, OR 97216 by July 1. VBS (9:00-11:45) Campers are children ages 4-5. Youth entering grades 7-12 are invited to apply as assistants. Registration: $15/camper* ($40 maximum per family). Includes healthy snacks.

More information:

For Day Camp, college-age counselors from Camp Lutherwood Oregon lead games, stories, and crafts.

Each day starts with music and introduction of the theme for the day, sometimes with skits or a puppet show.

Children should wear comfortable play clothes and shoes. Shoes should fit securely; no flip-flops, please.

For more information, please contact Gethsemane at 503.256.8219 or Maureen Hagen at maureenhagen@gmail.com.

DAY CAMP & VBS – REGISTRATION 2013

Camper’s Name

Nickname Grade Entering Fall 2013

M ( ) F ( ) Birthdate Age

Parent/Guardian Name(s)

Mailing Address

City/State/Zip

Day Phone Night Cell

Email address(es)

Home church City IN CASE OF EMERGENCY, PLEASE NOTIFY:

Name

Relationship to camper

Best way to contact APPROVED DRIVERS

Person(s) picking up the child Driver’s Phone Number Relationship to Parent/Child __ __ My child has permission to walk home or ride a bike home from Day Camp. ___ Yes ___ No Camp Lutherwood will provide the leaders of this year’s day camp, but many others will teach and help out. We volunteer our time because we see this as part of our normal ongoing ministry.

*The registration fee helps defray the cost of educational materials, snacks, and craft supplies for your child for the entire week and enables us to maintain the quality program that we now offer. Because we welcome all children, regardless of ability to pay, scholarship assistance is available to families in need. Please let us know when you register if your family requires scholarship assistance.

Please fill both sides of the registration form and submit to Gethsemane Lutheran Church, 11560 SE Market Street, Portland, OR 97216 by July 1.