EmailMe Form - Pines Presbyterian Church

NOTES

Enrollment is limited and acceptance is based on availability at the time of registration. Parents will be notified if camp has reached capacity.

Your child must be 4 years of age and potty-trained (by July 1st) through entering 5th grade in order to participate in Life Camp 2021. There will be a snack time each day.

Please fill out a separate form for each child participating.

PARTICIPANT INFORMATION

Student Name: *

Name of your home church:

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Home Phone: *

### - ### - ####

Alternative Phone:

### - ### - ####

Mother’s name: *

Father’s name: *

Child’s Date of Birth: *

MM / DD / YYYY

(month/day/year)

Parent’s email: *

Grade (or pre-K age) your child will be enrolled in, starting the Fall of 2021:

EMERGENCY CONTACT

Name: *

First Last

Phone: *

### - ### - ####

Alternative Phone:

### - ### - ####

Relationship: *

Please list and explain any medical conditions and/or food allergies:

PAYMENT INFORMATION

Registration is $5 per child or $10 per family.
(scholarships are available upon request)

3 options with how you may pay:

1. Complete this form and submit the payment form next (to follow).

or 2. Send Check
Please make checks payable to: Pines Presbyterian Church
Write "Life Camp 2021" on the memo line.

Mailing address:
Pines Presbyterian Church
Attention: Life Camp 2021
12751 Kimberley Lane
Houston, TX 77024

or 3. Bring your completed form and payment to the church office front desk and place in the Christian Education mailbox.

AUTHORIZATION

Today’s Date *

MM / DD / YYYY

Your name: *

has my permission to attend Life Camp 2021 on Aug. 2-5, from 9:00am to 11:30am. I agree for my child’s photograph to be taken and used in future publicity for Pines Presbyterian Church. All personal information about my child will not be disclosed at any time. In the event that I cannot be reached in an emergency, I hereby give permission to the physician or EMT personnel selected to secure and administer treatment, including hospitalization, for the participant named above.

Name of parent or guardian: *

Insurance company name: *

Policy# *

Group # *

Phone number of insurance authorization: *

Primary care physician name: *

Primary care physician phone: *

### - ### - ####

> > > NOTE:
If you're paying online, you'll be automatically directed to the secure payment form after clicking on the "SUBMIT" button (below):

On the next form, please specify:

$5/child
or $10/family

NOTES

PARTICIPANT INFORMATION

EMERGENCY CONTACT

PAYMENT INFORMATION

AUTHORIZATION

> > > NOTE: If you're paying online, you'll be automatically directed to the secure payment form after clicking on the "SUBMIT" button (below):

> > > NOTE:
If you're paying online, you'll be automatically directed to the secure payment form after clicking on the "SUBMIT" button (below):