here - Presbyterian Church of Western Springs

Music and Drama (MAD) Camp
FOR CHILDREN ENTERING GRADES K - 8
CHILD PARTICIPANT REGISTRATION FORM
Monday – Friday, June 8 – 12 (2:00 p.m. – 5:00 p.m.)
Registration Deadline: May 31, 2015
Child First Name____________________________________ Nick Name: _____________________
Child Last Name: _________________________________________
Gender: M F
Birthday: ______________________ Age: _______ Grade Entering in Fall: __________
__________________________________________________________________________________
Primary Parent/Guardian Name: _______________________________________________________
Street: ____________________________________________________________________________
City: _______________________________________ State: __________ Zip: ___________________
Home Phone: _______________________________ Alternate Phone: ________________________
Email address: _____________________________________________________________________
__________________________________________________________________________________
Other Persons (in addition to above) authorized to pick up your child after MAD Camp:
Name: ______________________________ Phone Number: _______________________________
Name: ______________________________ Phone Number: _______________________________
In Case of emergency (if primary parent/guardian cannot be reached) please contact:
Name: _________________________________
Phone Number: _________________________ Relationship to Child: _________________________
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MAD Camp Registration 2015
List any Special Medical Conditions (e.g., allergies to medicine or food, chronic illnesses or other
conditions): _______________________________________________________________________
__________________________________________________________________________________
Any Special Learning Concerns:________________________________________________________
Foods your child cannot eat: __________________________________________________________
Current medications (prescription and/or over-the-counter)
__________________________________________________________________________________
__________________________________________________________________________________
Registration Fee (Includes all materials and T-Shirt)
$20 per Child/ $30 per Family Payment attached
Payment made online
Need-based scholarships are available
Contact Rev. Jennifer Burns Lewis 708-246-5220 or [email protected]
__________________________________________________________________________________
I GIVE PERMISSION FOR MY CHILD TO PARTICIPATE IN MAD Camp, June 8-12, 2015:
I hereby give permission for the Presbyterian Church of Western Springs to procure all necessary
medical help for my child while he/she is under direct supervision of the Presbyterian Church of
Western Springs, and grant permission to its representatives to authorize any competent medical
person to do all things necessary to take care of any injury or sickness while my child is under the
supervision of the Presbyterian Church of Western Springs.
I hereby give permission for photos and or videos of me/my child taken during the event to be used
as follows: [(check box(es) to give permission. You may leave both unchecked.]
For internal PCWS use (posters or slide shows)
For use on PCWS website (no name will be given)
Parent/Guardian Signature __________________________________ Date __________________
Yes, I'd love to help with MAD Camp... please contact me about opportunities!
Home Church: PCWS
Other (please provide) __________________________________
For more information, contact Patti Mangis at 708-246-5220 or [email protected]
Presbyterian Church of Western Springs
5250 Wolf Road
Western Springs, IL 60558
MAD Camp Registration 2015