Summer Camp 2013

May 28August 14

5025 Lakewood Ave, St. Louis, MO 63123 314-353-9242 mariepivirotto@slcas.org

STUDENT AND FAMILY CONTACT INFORMATION

Student Name ______________________________ Grade 2013-14 ____ Date of Birth ____/____/_____ Student Name ______________________________ Grade 2013-14 ____ Date of Birth ____/____/_____ Student Name ______________________________ Grade 2013-14 ____ Date of Birth ____/____/_____ Please list the school(s) your child(ren) attend:__________________________________________________________

FAMILY INFORMATION
First and Last Name
(please print)

Father/Legal Guardian

Mother/Legal Guardian

Home Phone Number ( Cell Phone Number ( Home Address City, State, Zip Code Email Address Work Name/Occupation Work Phone Number ( Work Address City, State, Zip Code

) )

( (

) )

Student (s) Resides with: Father

Mother BOTH

(Other)

EMERGENCY CONTACT and PICK-UP INFORMATION

EMERGENCY CONTACTS (other than Parent/Guardian who may pick up student (s)) Name: ____________________________________________________ Relation: __________________________________ Phone (home/work/cell): Phone (home/work/cell): ( ( )______-__________ )______-__________ ( ( )______-__________ )______-__________ ( ( )______-__________ )______-__________ Name: ____________________________________________________ Relation: __________________________________ Persons NOT ALLOWED to pick up student (s). Any legal paperwork must be provided to the office: Name: ____________________________________________________ Relation: __________________________________

Health Information Please specify any health concerns (list by student): _________________________________________________________________________________________ _________________________________________________________________________________________ My/our child(ren) is/are subject to the following allergies or medical conditions, and I/We authorize Salem to disclose such allergies or medical conditions to a licensed medical doctor in the event my/our child(ren) should require emergency medical or dental care. I/We also authorize Salem to dispense medication Allergies, Medical conditions, and Medicine(s): _________________________________________________________________________________________ _________________________________________________________________________________________ Please List the Hospital(s) you prefer: _________________________________________________________________________________________
M on
closed
June 3

Calendar In order to help us plan for our summer activities and staffing, please indicate any days which you plan to NOT attend Salems Summer Camp Program. All days that are not marked will be assumed that your child/children WILL attend Salems Summer Camp Program.

Tues
First Day May 28 4

Wed
29

TH
30

Fri
31

June 10
VBS Week

11
VBS Week

12
VBS Week

13
VBS Week

14
VBS Week

June 17

18

19

20

21

June 24

25

26

27

28

July 1

CLOSED

July 8

10

11

12

July 15

16

17

18

19

July 22

23

24

25

26

July 29

30

31

August 1

Office Use Registration Fee $________ Date __________________

August 5

August 12

13

Last Day 14

Office Copy

Salem Lutheran Church and School

Parent/Guardian Commitment Summer Camp 2013
I/We, the undersigned parent(s)/guardian(s) of ______________________________________________________________________________________________
Print Student(s) Name(s)

1.

Give my/our permission for him/her to participate in any and all activities conducted or sponsored by Salem Lutheran Church and School (Salem). I/We understand staff personnel of Salem or other qualified responsible persons will supervise all activities conducted or sponsored by Salem.

2. 3. 4. 5.

Pledge my support and agreement with the standard of conduct and discipline of Salem Lutheran School as outlined in the Parent/ Student Handbook (Current copy is available on-line and from the office by request). Give Salem Lutheran School permission to use my childs photograph and/or artwork to be used in any future publication, newsletter, marketing tool, school website or other related school matter. (INITIAL if you DO NOT give consent: ____________.) Permit my/our child to participate in activities conducted or sponsored by Salem. I/We, on behalf of my/our child, and individually, hereby indemnify, release, and hold Salem harmless to the fullest extent permitted by Missouri law. Understand Salem provides liability insurance coverage for all Salem sponsored activities. I/We agree that this insurance is secondary to my/our own, which is agreed as being primary. In the event of injury to a non-insured participant, and in the event of a claim against the insurance carrier for Salem, I/We agree to pay or reimburse Salem for the deductible payment required by the insurance carrier.

6.

In the event of special situations, such as those arising out of medical needs, disciplinary action or other personal circumstances, which require or result in special transportation, communication, handling or liability expenses, I/We agree to assume full financial responsibility for all such costs.

7.

As parent/guardian, I/We hereby authorize and direct the treatment by a qualified and licensed medical doctor of my/our child in the event of a medical or dental emergency which, in the opinion of the attending physician, may endanger his/her life, or cause disfigurement, physical impairment, or undue discomfort if delayed. The authority is granted after a reasonable effort has been made to reach me/us.

I HAVE CAREFULLY READ THIS RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN ME/US AND SALEM LUTHERAN CHURCH AND SCHOOL. NO ORAL REPRESENTATIONS, STATEMENTS, OR INDUCEMENTS APART FROM THIS RELEASE HAVE BEEN MADE TO ME. I HAVE READ AND COMPLETED THE REGISTRATION MATERIALS AND AGREE TO FULFILL ALL THE POLICIES AS HEREIN PRESCRIBED. ________________________________ __________________________________ ____________________ Parent/Guardian (PRINT NAME) Parent/Guardian (SIGNATURE) Date ________________________________ Parent/Guardian (PRINT NAME) __________________________________ Parent/Guardian (SIGNATURE) ____________________ Date

Non-discriminatory Policy: Salem Lutheran School does not discriminate in any manner contrary to law or justice on the basis of race, color, gender, sexual orientation, age, religion, disability, veterans status or national origin in its educational programs or activities, including employment and admissions. At the same time, Salem Lutheran School cherishes its right and duty to seek and retain a student body and personnel who will make a positive contribution to its religious character, goals, and mission in order to enhance the Lutheran, Christian tradition.

Office Copy

Summer Camp 2013

5025 Lakewood, St. Louis, MO 63123 Phone: 314-353-9242 FAX: 314-353-9328 Latchkey/ Summer Direct Line - 314-353-5032

Calendar
*This page is for you. Please keep and use the calendar to mark the days you will not be at camp.
June 3

T
First Day May 28 4

W
29

TH
30

F
31

Cost/Fees Summer Registration Fee: $75 (one time fee/ per child and must be paid in full before the first day of attendance) The registration fee covers snacks, materials, and on-site field trips.

June 10
VBS Week

11
VBS Week

12
VBS Week

13
VBS Week

14
VBS Week

June 17

18

19

20

21

June 24

25

26

27

28

July 1

CLOSED July 4

July 8

10

11

12

Cost: $3 per hour (Additional Discounts for multiple children (20% off each)) Invoices will be sent home weekly.

July 15

16

17

18

19

July 22

23

24

25

26

July 29

30

31

August 1

August 5

August 12

13

Last Day 14

Parent/Guardian Copy

Salem Lutheran Church and School

Parent/Guardian Commitment Summer Camp 2013
I/We, the undersigned parent(s)/guardian(s) of ______________________________________________________________________________________________
Print Student(s) Name(s)

1.

Give my/our permission for him/her to participate in any and all activities conducted or sponsored by Salem Lutheran Church and School (Salem). I/We understand staff personnel of Salem or other qualified responsible persons will supervise all activities conducted or sponsored by Salem.

2. 3. 4. 5.

Pledge my support and agreement with the standard of conduct and discipline of Salem Lutheran School as outlined in the Parent/Student Handbook (Current copy is available on-line and from the office by request). Give Salem Lutheran School permission to use my childs photograph and/or artwork to be used in any future publication, newsletter, marketing tool, school website or other related school matter. (INITIAL if you DO NOT give consent: ____________.) Permit my/our child to participate in activities conducted or sponsored by Salem. I/We, on behalf of my/our child, and individually, hereby indemnify, release, and hold Salem harmless to the fullest extent permitted by Missouri law. Understand Salem provides liability insurance coverage for all Salem sponsored activities. I/We agree that this insurance is secondary to my/our own, which is agreed as being primary. In the event of injury to a non-insured participant, and in the event of a claim against the insurance carrier for Salem, I/We agree to pay or reimburse Salem for the deductible payment required by the insurance carrier.

6.

In the event of special situations, such as those arising out of medical needs, disciplinary action or other personal circumstances, which require or result in special transportation, communication, handling or liability expenses, I/We agree to assume full financial responsibility for all such costs.

7.

As parent/guardian, I/We hereby authorize and direct the treatment by a qualified and licensed medical doctor of my/our child in the event of a medical or dental emergency which, in the opinion of the attending physician, may endanger his/her life, or cause disfigurement, physical impairment, or undue discomfort if delayed. The authority is granted after a reasonable effort has been made to reach me/us.

I HAVE CAREFULLY READ THIS RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN ME/US AND SALEM LUTHERAN CHURCH AND SCHOOL. NO ORAL REPRESENTATIONS, STATEMENTS, OR INDUCEMENTS APART FROM THIS RELEASE HAVE BEEN MADE TO ME. I HAVE READ AND COMPLETED THE REGISTRATION MATERIALS AND AGREE TO FULFILL ALL THE POLICIES AS HEREIN PRESCRIBED. ________________________________ __________________________________ ____________________ Parent/Guardian (PRINT NAME) Parent/Guardian (SIGNATURE) Date ________________________________ Parent/Guardian (PRINT NAME) __________________________________ Parent/Guardian (SIGNATURE) ____________________ Date

Non-discriminatory Policy: Salem Lutheran School does not discriminate in any manner contrary to law or justice on the basis of race, color, gender, sexual orientation, age, religion, disability, veterans status or national origin in its educational programs or activities, including employment and admissions. At the same time, Salem Lutheran School cherishes its right and duty to seek and retain a student body and personnel who will make a positive contribution to its religious character, goals, and mission in order to enhance the Lutheran, Christian tradition.

Parent/Guardian Copy