Complete the information below. Parents will need to complete a separate form for each child.
Date of Birth*
Grade Entering Fall 2018*
Emergency Contact (Name)*
Emergency Contact Phone #*(
Are there any special medical conditions (include allergies) and/or medications which Fitness Staff should be aware?
Describe or list below
We will try to accommodate all children with special needs with inclusion buddies, adapted activities and low-sensory spaces. If you wish to be contacted by our Accommodation Specialist, in order to develop a plan for inclusion for your child, please check the box below.
Yes, please contact me
Is there any additional information we should know about your child that would be helpful?
If desired you may request your child to be placed in a rotation group with one other child. Note: Children must be within 1 grade of each other and registered no later than July 15. Please list your child's first name and the full name of the child you want your child placed with. While we cannot guarantee your child will be in the same group as the child you request, we will make every effort to meet your request.
PARENT: I, the above signed parent or person having legal custody or the legal guardian of the above-named minor give permission for the above named minor to participate in Fitness Camp from Monday, July 23rd – Friday, July 27th, 2018 and do hereby authorize Kathleen Cantwell or any volunteer appointed by Kathleen Cantwell to consent to any x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care to be rendered to the above named minor under general or special supervision and upon the advice of a physician, surgeon or dentist licensed under the laws of the state they practice in. In giving this consent I recognize and understand that in situations where the above named minor requires immediate medical or hospital care it may not be possible to contact me, in such situations I will not be able to knowledgeably evaluate and choose among the available alternative treatments or procedures, if any, or to evaluate the risk attenuate upon each, and the risk attenuate to forgoing all treatment; in such situations, I authorize a physician, surgeon or dentist to exercise his professional judgment and assess the risk incident and choose the necessary treatment from any available alternatives and to render such care and perform such treatment as he in his professional judgment determines to be necessary for the health or safety of the above-named minor. I also agree to reimburse any expenses not covered by the church’s insurance. I will not hold the church or any of the workers responsible for any illness or injury to my child.
PHOTOGRAPH/VIDEO NOTICE I understand that as a participant, my child may be photographed or videotaped during normal meetings or special events. I understand that the videos or photographs may be used in promotional materials for Grace Community Baptist Church.