First & Last Name *Preferred Name (Optional) Birth Date: *Last School Grade Completed (If Pre-K, then type in Pre-K): *Home Address: *Address Line 1Address Line 2CityStateZip CodeParent/Guardian Name(s): *Parent/Guardian Phone Number: *Parent/Guardian Email Address: *Emergency Contact Name: *Emergency Contact Phone Number: *Physician's Name: *Physician's Phone Number: *Insurance Carrier: *Insurance Policy/Group Number: *Name of Home Church: Home Church City & State: Any Restrictions to Physical Activities? *Any Allergies (Food, Drugs, Insects, Etc.)? *How did you hear about Day Camp? I will not hold Lutherhill Ministries, it's staff, Alvin Lutheran Church, Congregational Employees, or Congregational Volunteers, responsible for accidents, claims, and damages arising from my child's participation in Day Camp Activities. I also give Lutherhill Ministries permission to use any photograph/video of me or my child, taken at Day Camp, in future promotional materials for its sites and programs. *I AgreeI Do Not AgreeDay Camp Registration Form Upload (For Paper Copies Only) Drop your file here or click here to upload EmailSubmit