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St. John’s Lutheran Church of Orange
Summer Day Camp Registration 2018 FOR Children entering 1st grade through 6th grade in the fall of 2018
ONE FORM PER CHILD Please Print
M F
Child’s Name
DOB
/
/
Baptized? Yes
No
Address City ____________________________ State Grade in Fall 2018
Zip
Phone (
)
School Attending in Fall
Church Attending:
Member?
Mother/Guardian
Yes No
Cell Phone (
Father/Guardian
)
Cell Phone (
Child is living with
both parents
mother only
If divorced, who has legal custody
joint
mother only
father only father only
Primary Email name:
email:
Secondary Email name:
email:
Emergency Contact 1 (Other than Parent) _________________________________________Phone ( Emergency Contact 2 (Other than Parent) ________________________________________Phone ( Allergies/Medical Conditions
)
____________________________________________________________
court papers attached
) )
Epi Pen
inhaler
__________________________________________________________________________________________________________________________________
Please indicate size: T-Shirt: (check one)
Child Sizes: Adult Sizes:
XS (2-4) SM (6-8) SM (32-34) M (36-38)
M (10-12) L (40-42)
L (14-16) XL (44-46)
St. John’s Orange • 154 S. Shaffer St., Orange, CA 92866 • 714.288.4400
Release and Hold Harmless Agreement and Waiver of Liability 2018 I, the undersigned guardian, allow ____________________________________________ to participate in Summer in the Son day camp activities from June 4-August 10, 2018, sponsored by the Family Ministry at St. John’s Lutheran Church of Orange all of which are hereinafter referred to as the “activity”. I consent permission for participation in the activity and acknowledge that I fully understand the participation may involve risk of serious injury or death, including losses which may result not only from the participant’s actions, inactions or negligence, but also from the actions, inactions, or negligence of others, the condition of the facilities, equipment, or areas where the event or activity is being conducted, and/or the rules of play of this type of event or activity. I am aware that participation in the activity may require the participant to be transported by busses to and from campus and the expectation is to abide by the policies and procedures of the contracted transportation company. I understand that if I have any concerns about risk, I should discuss the risks associated with participation with the activity coordinators and event staff, before I sign this document and before the activity begins. If volunteers, adult leaders or parents drive their own vehicles, I am aware if they have an accident that my personal insurance will be the “primary” insurance and that St. John’s Lutheran Church of Orange will be the secondary insurance. In addition, St. John’s Lutheran Church of Orange will not be held responsible for physical damage that occurs while using personal vehicles for the activity. I understand this activity is not required for the participant and I assume all reasonable risk for the participant attending an activity that may occur off-campus. I certify that the participant is in good health and has no physical condition that would prevent participation in this activity. Furthermore, I agree to use my personal medical insurance as a primary medical coverage payment if accident or injury occurs to the participant. I consent to emergency medical treatment in the event such care is required. I am aware that upon being injured, the participant may solicit the assistance from St. John’s staff and youth ministry team and if he/she chooses to do so, I assume all reasonable risk. I agree that photographs, pictures, slides, movies, video, or other media coverage of the participant may be taken in connection with participation in the activity without compensation from St. John’s Lutheran Church of Orange, its officers, employees, representatives, volunteers or agents, or any of them, and I consent to the use of photographs, pictures, slides, movies, videos, or other media coverage for any legal purpose. Knowing and understanding the risks involved with participation in the activity, I hereby voluntarily and willingly assume responsibility for all risks and dangers for the participant in the activity. I agree I am financially responsible for any losses resulting from the participant’s actions and will indemnify St. John’s Lutheran Church of Orange, its officers, employees, representatives, volunteers and agents, and each of them, for any loss or damage caused by the participant during this activity. In consideration of participation in the activity, I hereby waive all claims or causes of action against St. John’s Lutheran Church of Orange, its officers, employees, representatives, volunteers and agents, and all of them, arising out of participation in the activity and hereby release, hold harmless, and discharge St. John’s Lutheran Church of Orange, its officers, employees, representatives, volunteers and agents, and each of them, from all liability in connection therewith except such loss or damage which was caused by the willful misconduct of St John’s Lutheran Church of Orange, its officers, employees, representatives, volunteers or agents. This waiver and release is freely and voluntarily given with the understanding that right to legal recourse against St. John’s Lutheran Church of Orange, its officers, employees, representatives, volunteers or agents, or any of them, is knowingly given up in return for allowing the participant to participate in the activity. My signature on this document is intended to bind not only myself and the participant, but also my successors, heirs, representatives, administrators, and assigns.
I have read this release and hold harmless agreement and waiver of liability, and I understand the terms used in it and their legal significance. Participant’s name__________________________________ Guardian’s signature____________________________ Date_________ Emergency contact name (print) Phone # Relationship to participant ____________________________________________________ Please utilize the space below to provide any medical/prescription Information that you request be released to emergency medical providers.
Child’s Name _______________________________
St. John’s Summer Day Camp 2018
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St. John’s Lutheran Church of Orange
Parent Agreement Form 2018 Tuition Payment I agree to pay all tuition and fees as indicated on signed registration form. Tuition will be billed weekly for St. John’s Lutheran School students through their FACTs account. This fee will be an incidental fee for summer camp. Non-SJLS students will be billed weekly through emailed invoices. Payments for non - St John’s students may be made by cash or check only. Please note: all payments are due within 10 days of the billing date. Late fees of $35 will accrue if not paid. Also, families must stay current on their payments or their child will be ineligible to attend Summer in the Son summer camp. Registration fees will be billed with first week of attendance. Parent/Guardian signature
Date
Split Billing (Initials) I understand that if split billing is requested it will be done on a 50/50 basis. I also understand that each party must have a signed registration form and parent agreement form. ________ (Initials) I DO request split billing; split with____________________________________________(Name) ________ (Initials)I DO NOT request split billing Initial only one Schedule Changes (Initials) I understand that I may make changes of adding days or deleting days from my summer schedule and must submit changes in writing a minimum of one week prior to event. Please use Summer in the Son Change Request Form found at www.stjohnsorange.org/daycamp and email it to
[email protected] or print it out and drop it off in the box in the SAC house. Please note that space is limited and changes will be made as space permits. If change form is not received, you will be billed for days/weeks for which you are registered and child does not attend. Late Pick Up Fees _____ (Initials) I understand a late pick-up fee of $1.00 per minute, per child past 6:00 p.m. with no cap will be billed with weekly tuition expenses. Peanut/Nut Allergy _____(Initials) I clearly understand that St. John’s is not a peanut/nut free environment and that there is the possibility for contact with peanuts and or peanut related products. Although reasonable efforts will be made to ensure safety, I understand that there is a possibility of peanut/nut exposure. Illness _____(Initials) I understand my child or children will not be permitted to attend camp if ill. Cell Phones, Toys, Electronics and iPads From Home_____(Initials) I understand that cell phones, toys, electronics, and iPads from home are permitted on specified days only. Cell phones may be used with staff permission/supervision for contacting parents. A cell phone is available for them to use. I agree to the following discipline Policy _____ (Initials) Should there be a behavior/discipline problem with your child during the summer camp program, you may be called to pick-up your child immediately at the discretion of the summer camp director. If a child continues to have a behavior/discipline problem, he/she may be removed from the summer camp program at the discretion of the director. St. John’s Orange • 154 S. Shaffer St., Orange, CA 92866 • 714.288.4400
Child’s Name _______________________________ Grade Entering Fall ________
St. John’s Summer Camp 2018 Turn in this form in
St. John’s Lutheran Church of Orange Dates and Tuition Agreement 2018 Non-refundable One-TimeRegistrationFee (includes1 t-shirt):
1 child…….$25 2 children…….. $40 ($20 each) Registration fee will be charged with first day attended.
3 children $45 ($15 each)
TuitionFees -- Non-refundable but may bechanged accordingto Change Request Form 5days $200 4days $165 3days $130 VBSfreeforweek ofJune18-22with purchaseof3 ormore days ofcamp 2days $ 90 Closed July4th 1day $ 55 Field trip On-SiteEvent Swim Day-- walk toHartPark
Mark daily choice with X. Please see Attached Schedule for specific dates. Events subject to change. Week
Month
Theme
1
June 4-8 June 11-15 June 18-22
Summer CarnivalKidkoffInflatables & carnivalgames Soc-cerItto Me
2 3 VBS
VBSin morning
He-roes & She -roes Incredibles movie/herovisit
5
July 2-6
I theUSA
6
July 9-13 July 16-20
Into the Wild
9 10
July 23-27 July30Aug 3 Aug 6-10
Wed. STEM
Thu.
Fri.
+Reg. Fee
TOTAL DUE
NoSTEM
Treasure Quest
June 25-29
8
Tues
Soccerclinic/RockinJump
4
7
Mon.
Pirateinflatable/Pirate’sDinnerTheater
Nerf Party
CLOSED 4thof July
ReptileParty/Santa Ana Zoo
Shark Week
Aquarium ofthePacific/ sharkriderinflatable
Spaced Out!
DiscoveryScienceCube/lasertag
Rock ‘n Soul
Rock walll/karaoketalentshow
Time to Bounce Rockin Jump/ Bubblemania/inflatables
Parent/Guardian Signature_________________________________________________________
Date______________
St. John’s Orange • 154 S. Shaffer St., Orange, CA 92866 • 714.288.4400
Name
2018
Mark days & RETURN this form with registration packet events subject to change. Revised 3.19.18
Bible Focus
Week
Compete for the ultimate prize
Week
1 Cor. 9:25 Nations will come to your light Isaiah 60:3 We are powerful people! Acts 1:8
1 June 4-8
Week
2
June 11-15 Week
3
June 18-22 12:156:00pm
Where’s your treasure Matt. 6:21
Week
4
June 25-29
Weekly Theme Summer Carnival Kickoff Soc-cer It To Me
VBS in a.m.
Monday 4
Gaga Ball
11 Sarah K. Soccer Clinic
18
Prov. 11:25 Creation Restored
Isaiah 11:6-9
Week
5
July 2-6 Week 6 July 9-13
5
Stem-tastic
Wednesday
12 Giant Inflatable Soccer Ball #1 foam finger craft 19
7
8
Dunking Booth Carnival games
13/ STEM
14
15
CHAPEL
Giant Flag Football
The mysterious floating golf ball 20/NO STEM
I the USA Into the Wild!
2
26 Dress & talk like a Pirate Day Treasure Hunt 3
27/ STEM
Week
He names and counts the stars
Week
Psalm 147:4
God’s great dance floor Psalm 149:3 Let’s press onward Phil. 3:14
7
July 16-20
8
July 23-27 Week
9
July 30Aug.3 Week 10 Aug. 6-10
21
A different kind of hero
Gaga Ball
Shark Week
28
Dinner theater
Closed for July 4th
Nerf Party!
Rock ‘n Soul Time to Bounce
$200 $165 $130 $ 90 $ 55
TOTAL: $ Number of Days
___________ TOTAL: $___________ 22 Giant Games Heroes vs Villains Cannonball Bowling Connect 4 29
Number of Days
Swim at Hart Park
___________ TOTAL: $___________
6
Number of Days
Swim at Hart Park
___________ TOTAL: $___________
___________ TOTAL: $___________
Number of Days
Field trip 5 Wet & Wild
9 Square in the Air
9
10
11/ STEM
13
Number of Days
Reptile Party
Swim at Hart Park
CHAPEL Monkey Soccer
___________ TOTAL: $___________
12Field trip
JUNGLE FIRE WATER GAMES
19
20
Number of Days
16
26
18/ STEM
CHAPEL
Sea Slime
Swim at Hart Park
Gaga Ball
Spaced Out!!
5 days 4 days 3 days 2 days 1 day
Field trip
CHAPEL
Pirate Crafts Pirate Ball 4
COST *plus
registration fee
Field trip
Treasure Quest
events subject to change
Giant Twister
make your own super hero cape
25
Friday
6/ STEM
wooden snakes The seas obey the King Matt. 8:27
Thursday
CHAPEL
9 Square Mega balloon in the Air launcher Giant Jenga Tug of war
He-roes & She-roes
Pirate Bouncer Blessed to be a blessing
Tuesday
23
24
CHAPEL
Neon 9 Square in the Air 30 You rock (literally!) Rock candy 6
25/ STEM Galactic Slime Hovercraft project GYM games
26
Swim at Hart Park
Shark rider 27
Number of Days
Laser Tag
___________ TOTAL: $___________
3
Number of Days
31
August 1/STEM
2
Rock Climbing
CHAPEL
Swim at Hart Park
Karaoke
9
10
special guest worship leader 7
8 /STEM
CHAPEL Bouncy Balls Rubber eggs
___________ TOTAL: $___________
Talent Show
___________ TOTAL: $___________ Number of Days
___________ TOTAL: $___________
Revised 3.19.18
KEEP AT HOME for REERENCE
Bible Focus
Week
Compete for the ultimate prize
Week
1 Cor. 9:25 Nations will come to your light Isaiah 60:3 We are powerful people! Acts 1:8
1 June 4-8
Week
2
June 11-15 Week
3
June 18-22 12:156:00pm
Where’s your treasure Matt. 6:21
Week
4
June 25-29
Weekly Theme Summer Carnival Kickoff Soc-cer It To Me
VBS in a.m.
Monday 4
Gaga Ball
11 Sarah K. Soccer Clinic
18
Prov. 11:25 Creation Restored
Isaiah 11:6-9
Week
5
July 2-6 Week 6 July 9-13
5
Stem-tastic
Wednesday
19
He-roes & She-roes
7
8
Giant Twister
Dunking Booth Carnival games
13/ STEM
14
15
CHAPEL Mysterious floating golf ball 20/NO STEM
Treasure Quest I the USA Into the Wild!
2
26 Dress & talk like a Pirate Day Treasure Hunt 3
27/ STEM
Gaga Ball
Nerf Party!
Week
He names and counts the stars
Week
Psalm 147:4
God’s great dance floor Psalm 149:3 Let’s press onward Phil. 3:14
7
July 16-20
8
July 23-27 Week
9
July 30Aug.3 Week 10 Aug. 6-10
Shark Week
21
A different kind of hero 28
Rock ‘n Soul Time to Bounce
Number of Days
22 Giant Games Heroes vs Villains Cannonball Bowling Connect 4 29
Number of Days
Swim at Hart Park
___________ TOTAL: $___________
6
Number of Days
Swim at Hart Park
___________ TOTAL: $___________
___________ TOTAL: $___________
Number of Days
Field trip 5 Wet & Wild
9 Square in the Air
9
10
11/ STEM
13
Number of Days
Swim at Hart Park
CHAPEL Monkey Soccer
___________ TOTAL: $___________
12Field trip
JUNGLE FIRE WATER GAMES
19
20
Number of Days
16
26
18/ STEM
CHAPEL
Sea Slime
Swim at Hart Park
Gaga Ball
Spaced Out!!
TOTAL: $
Reptile Party
wooden snakes The seas obey the King Matt. 8:27
$200 $165 $130 $ 90 $ 55
Field trip
Dinner theater
Closed for July 4th
5 days 4 days 3 days 2 days 1 day
___________ TOTAL: $___________
Giant Flag Football
CHAPEL
Pirate Crafts Pirate Ball 4
COST *plus registration fee
Field trip 25
Friday
6/ STEM
9 Square Mega balloon in the Air launcher Giant Jenga Tug of war 12 Giant Inflatable Soccer Ball #1 foam finger craft
Thursday
CHAPEL
make your own super hero cape
Pirate Bouncer Blessed to be a blessing
Tuesday
23
24
CHAPEL
Neon 9 Square in the Air 30 You rock (literally!) Rock candy 6
25/ STEM Galactic Slime Hovercraft project GYM games
26
Swim at Hart Park
Shark rider
___________ TOTAL: $___________
27
Number of Days
Laser Tag
___________ TOTAL: $___________
31
August 1/STEM
2
3
Number of Days
Rock Climbing
CHAPEL
Swim at Hart Park
Karaoke
___________ TOTAL: $___________
9
10
special guest worship leader 7
8 /STEM
CHAPEL Bouncy Balls Rubber eggs
Talent Show
Number of Days
___________ TOTAL: $___________
